Online Child Application

Please fill out to the best of your ability and then hit the “Submit” button at the bottom of the page.
* Indicated required fields

Child Application

Full Legal Name*
First Last
Age*
Please enter a number from 5 to 18.
Grade
DOB*
Month
Day
Year
Birthplace
SS Number
Sex*
- Female
- Male
Race
Religion
Height
Weight
Hair
Eye Color
Distinguishing Marks
Last Resided With
Relationship
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Legal Guardian
Relationship
Address
Street Address Address Line 2 City State ZIP Code
Phone
Prior Placement (Include foster care, hospitalizations, etc.)
First Last
Prior Placement Address
Street Address Address Line 2 City State ZIP Code
Date
Month
Day
Year
Prior Placement (Include foster care, hospitalizations, etc.)
First Last
Prior Placement Address
Street Address Address Line 2 City State ZIP Code
Date
Month
Day
Year
Prior Placement (Include foster care, hospitalizations, etc.)
First Last
Prior Placement Address
Street Address Address Line 2 City State ZIP Code
Date
MM slash DD slash YYYY
DHS or CPS Custody?
- Yes
- No
Date
Month
Day
Year
DHS or CPS Placement Reason
Discharge Reason
Court Record
Date
Month
Day
Year
Reason(s)
Case Worker/P.O. Name
Phone
Reason
How does child feel about placement at Tipton Children's Home?
Presenting Problem: Describe reason for placement at Tipton Children's Home
List child’s interests, hobbies, etc.
Family History: relatives or other interested persons
First Last Relationship
Address
Street Address Address Line 2 City State ZIP Code
Phone
Relatives or other interested persons
First Last Relationship
Address
Street Address Address Line 2 City State ZIP Code
Phone
Sibling (1)
First Last
DOB
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone
Sibling (2)
First Last
DOB
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone
Sibling (3)
First Last
DOB
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Phone
Birth Order
- First
- Second
- Third
- Forth
- Fifth
- Sixth
- Seventh
- Baby
- Adopted
- Twin
Biological Mother
First Last
DOB
Month
Day
Year
SS#
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Occupation
Employer
Monthly Salary
Work Phone
Length of employment
Biological Father
First Last
DOB
Month
Day
Year
SS#
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Ocupation
Employer
Monthly Salary
Work Phone
Length of employment
Financial: Is child entitled to any aid from Social Security?
- Yes
- No
If yes, amount
SS#
Financial: Is child entitled to any aid from Veterans benefits?
- Yes
- No
If yes, amount
Claim#
Financial: Is child entitled to any aid from child support?
- Yes
- No
If yes, amount
SS#
Name of Benefactor
First Last
Other source of income?
Amount
****I certify that I am not under any financial obligation while my child is a resident at the Tipton Children's Home. Therefore, I will provide $0 towards the child’s support.*
First Last
Date Signed
MM slash DD slash YYYY
Education: Usual grades of student
- A
- B
- C
- D
- F
Has the child ever repeated a grade?
- Yes
- No
Which grade(s)
Has the child ever been in Special Ed or remedial class?
- Yes
- No
Has the child ever been in gifted or talented classes ?
- Yes
- No
When?
Has the child ever: Been in speech therapy class?
- Yes
- No
Has the child ever been a discipline problem at school?
- Yes
- No
If so, please explain:
Has the child ever been:
- Suspended
- Expelled
- School detention
- Saturday school
- Truant
Current School Name
Address
Street Address Address Line 2 City State ZIP Code
Previous School Name
Address
Street Address Address Line 2 City State ZIP Code
Dates Attended
Previous School(s)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates Attended
Previous School Name
Address
Street Address Address Line 2 City State ZIP Code
Dates Attended
Medical History: Does child have a regular physician
- Yes
- No
If yes, name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Do you have health insurance that carries the child as a dependent?
- Yes
- No
If Yes, name of insurance and policy number
Has the child had a serious illness?
- Yes
- No
Please list
Date(s) / Dr. Name / Location(s)
Has the child had broken bone(s)?
- Yes
- No
Reason(s)
Date(s) / Dr. Name / Location(s)
Has the child been hospitalized?
- Yes
- No
Reason(s)
Date(s) / Dr. Name / Location(s)
Has the child had surgeries?
- Yes
- No
Reason(s)
Date(s) / Dr. Name / Location(s)
Does the child have any medical, dental, visual or psychological problems?
- Yes
- No
If Yes, please explain
List any medication the child is currently taking or has ever taken:
List medication name, Dr. who prescribed it, reason needed and how long the child has been taking the prescription.
Is the child allergic to medications, foods, bee stings or other?
List then explain
Does the child wear glasses/contacts?
- Yes
- No
If Yes, when was child’s last eye exam?
Month
Day
Year
Dr.
First Last
Address
Street Address Address Line 2 City State ZIP Code
Does the child wear braces?
- Yes
- No
If Yes, when was child’s last dental exam?
Month
Day
Year
Dentist
First Last
Cavities?
- Yes
- No
Has the child attended counseling?
- Yes
- No
Has the child had a psychological evaluation?
- Yes
- No
Psychologist name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Does the child have any tattoos?
- Yes
- No
If Yes, date of each
Does the child have or ever had any problem with the following:
Click on all applicable. Hold down Command key to choose more than one.
Description and date of onset for each item checked.
Intravenous Drug Use?
- Yes
- No
Date of last use
Month
Day
Year
If Female, has child started her period yet?
- Yes
- No
Date of last menstrual cycle?
Month
Day
Year
# of days?
Age of onset?
Possibility of being pregnant?
- Yes
- No
- Unsure
Date of last intercourse?
Month
Day
Year
Has the child used/or is currently using un-prescribed drugs, alcohol, or any form of tobacco? Please explain:
Your Name
First Last
Your Age
Date answering
MM slash DD slash YYYY
Below is a list of problems that the child may or may not be having. Please indicate the frequency of each problem by checking the appropriate answer.
Afraid of new situations
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Sad or unhappy most of the time
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Denies having done wrong
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Tells things that did not occur
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Clings to adults
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Restless sleep
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Has trouble falling asleep
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Cries often
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Soils self or clothing (urination or bowel)
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Wets the bed
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Acts younger than actual age
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Takes correction poorly
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Blames others for mistakes
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Bad relations with adults
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Has depressed attitude
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Has frequent headaches
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Complains of aches and pains
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Feels depressed a lot
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Discipline problem at school
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Keeps anger to self
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Steals from stores, etc.
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Bad relationship with other kids
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Has explosive temper tantrums
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Bullies other children
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Steals at home
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Uses profanity
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Abuses objects (furniture, etc.)
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Inappropriate sexual behavior
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Uses tobacco (smokes, chew, etc.)
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Uses alcoholic beverages
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Uses drugs
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Specify drugs please:
Gang involvement/ interest
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Lack of parental supervision
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Easily distracted
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Likes school
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Exhibits leadership qualities
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Considerate, helpful
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Affectionate
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Happy go lucky, playful
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Moody/emotion shift quickly
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Nervous, fearful, anxious
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Touchy, resents criticism
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Argues, criticizes others
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Curses, use abusive language
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Demands attention
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Resents discipline
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Scratches, cuts or hurts self
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Plays with fire/ matches
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Distorts the truth
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Specify habits please:
Hits, fights, attacks others
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Threatens to hurt others
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Makes friends easily
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Passive, easily influenced
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Vandalizes, destroys objects
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
Happy to come to the Tipton Children's Home?
- Never
- Rarely
- Seldom
- Occasionally
- Often
- Frequently
- Always/Extremely
Check most appropriate option.
What are your expectations of the Tipton Children's Home?
What areas does the child need help with?
If for some reason the child cannot stay at the Tipton Children's Home past the 30-day trial period or later, who will come to pick up the child?
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email
I hereby confirm that the above statements are true to the best of my knowledge.
Signature of Guardian
First Last Date
I hereby confirm that the above statements are true to the best of my knowledge.
Signature of Child
First Last Date

Tipton Children's Home

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Tipton Children's Home

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Child Application