Child Application We know you do not take the choice to place your child in our care lightly, and we are grateful! Step 1 of 9 11% 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*RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneLegal GuardianRelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Prior Placement (Include foster care, hospitalizations, etc.) First Last Prior Placement Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date MM slash DD slash YYYY DHS or CPS Custody?* Yes No Date Month Day Year DHS or CPS Placement ReasonDischarge ReasonCourt RecordDate Month Day Year Reason(s)Case Worker/P.O. NamePhoneReason 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRelatives or other interested persons First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSibling (1) First Last DOB MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSibling (2) First Last DOB MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSibling (3) First Last DOB MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneBirth 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneOccupationEmployerMonthly SalaryWork PhoneLength of employmentBiological Father First Last DOB Month Day Year SS#Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneOcupationEmployerMonthly SalaryWork PhoneLength of employment Financial: Is child entitled to any aid from Social Security?* Yes No If yes, amountSS#Financial: Is child entitled to any aid from Veterans benefits?* Yes No If yes, amountClaim#Financial: Is child entitled to any aid from child support?* Yes No If yes, amountSS#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 If yes, 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 NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous School NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates AttendedPrevious School(s)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Dates AttendedPrevious School Name*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have health insurance that carries the child as a dependent?* Yes No If Yes, name of insurance and policy numberHas the child had a serious illness?* Yes No Please listDate(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 explainList 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 explainDoes 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does the child have any tattoos?* Yes No If Yes, date of eachDoes the child have or ever had any problem with the following:*AllergiesAsthmaDiabetesHeart ProblemsHearing LossSeizuresEar TroubleFainting SpellsThroat TroubleChicken PoxHigh Blood PressureHyperactive/AdhdHepatitis A B CClick 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* Never Rarely Seldom Occasionally Often Frequently Always/Extremely Check most appropriate option.Discipline problems 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.Is the child 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Please upload social security card, birth certificate, and shot record with each application.*Max. file size: 50 MB.
