Online Admissions Form

Online Admissions Form
In addition to this form, you must submit the below forms for Access Counseling:

1) Medical Consent Form

2) Authorization for Release

3) Counseling Intake Packet

4) Tele-Health Consent

5) Minors Psychaitrc Services
What Facility is associated with person transporting new resident?*
Name of Person who transported new resident to OWF*

First NameLast Name
Resident's Name*

First NameLast Name
Admission Date*

MonthDayYear
Date
County*
Social Worker's Name*

First NameLast Name
Social Worker's Email*
example@example.com
Social Worker's Phone*

Area CodePhone Number
Resident's Probation Officer Name

First NameLast Name
Probation Officer Email
example@example.com
Probation Officer Phone Number

Area CodePhone Number
Guardian Ad Litem Name

First NameLast Name
Guardian Ad Litem Email
example@example.com
Guardian Ad Litem Phone Number

Area CodePhone Number
CASA

First NameLast Name
CASA Email
example@example.com
CASA Phone Number

Area CodePhone Number
After Hours Emergency Contact Number*

Area CodePhone Number
Resident's Registration Information

Please fill in all lines or answer N/A (Not Applicable)
Resident Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Upload important files

Browse Files
example: Social Security Card, Birth Certificate, Medical Card, Court Orders and Health & School District Forms Cancelof
Will The Resident be attending school this year?

YesNo
Our Residents will be attending the Fairfield City Schools. Each resident needs to go through their registration process. Please click on the link below to complete this form.

Final Forms Online Registration
Would you like to review the registration requirements and Instructions?

YesNo
Please enter Parental Information:
Does Resident have Medical Card?

YesNo
Does Resident have Private Insurance?

YesNoOther
Please enter Insurance Information:
Please enter Secondary Insurance Information:
Select Resident's Coverage:

MedicalDentalVisionOther
Please enter Dental Insurance Information:
Is Resident in counseling?

YesNo
If not will counseling be arranged?

YesNo
Counselor's Name

First NameLast Name
Counselor's Phone Number

Area CodePhone Number
Can Resident have haircuts?

YesNo
Case Worker Signature: Use Mouse to sign. Phone or Tablet - use finger to sign
I have received a copy of the City of Refuge DBA One Way Farm Resident and Family Handbook. I understand that City of Refuge DBA One Way Farm’s program is biblically based. I understand that as a part of the program, each child will be expected to attend church services and other activities at Calvary Tabernacle in Middletown, Ohio. While the expectation is that a child participates in church services and activities, he or she will not be coerced into doing so. I understand that on-going refusal to participate in religious services may influence whether a child is able to remain in placement.

YesNo
Resident's Signature
Caseworker's Signature
Medications
I give permission for Resident to receive the following prescription medications:
Please enter Resident Name
Please enter all prescription medication information below: Medicine 1
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 2
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 3
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 4
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 5
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 6
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 7
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 8
Would you like to add another medication?

YesNo
Please enter all prescription medication information below: Medicine 9
Custodial Agency or Caseworker Signature: Please use mouse to sign - phone or tablet, use finger
I give permission for Resident below to receive over the counter medications for fever, cough, and other minor illnesses per OWF Nurse:
Enter Resident Name
Custodial Agency or Caseworker Signature: Please use mouse to sign - phone or tablet, use finger
Activity Authorization Form
I give the Resident listed below permission to participate in extra-curricular activities checked below:
The following activities are permissible:

Field TripsSportsEmploymentKinship culturally diverse activitiesOutdoor work responsibilities such as yard work and gardeningTo attend local church services (functions) of his/her choiceTo attend services (functions) of Calvary Tabernacle and Cornerstone Church Of GodTo attend nightly devotionals and Bible Study
Custodial Agency or Caseworker Signature: on computer use mouse, on phone or tablet use finger to sign below:
Resident may have contact with the following people:

FatherMotherSister(s)Brother(s)Grandparent(s)Aunt/Uncle(s)Previous Foster Family
Father's Name
Mother's Name
Sister(s) Name(s)
Brother(s) Name(s)
Grandparent(s) Name(s)
Aunt/Uncle(s) Name(s)
Previous Foster Family Name
Type of visits allowed:

Supervised On GroundsSupervised Off GroundsUnsupervised Off GroundsOther
List person(s) that Resident is to have NO contact with:
Resident can go on overnight visits with friends?

YesNo
Can Resident go unsupervised on grounds?

YesNo
Can Resident go to school functions (unsupervised by One Way Farm Staff?

YesNo
Can Resident go to the Library unattended?

YesNo
When Resident reaches appropriate age, can Resident work a job?

YesNo
Briefly state circumstances:
Custodial Agency or Case Worker Signature - use mouse to sign, phone or tablet - please sign with finger
Counseling Services

The One Way Farm has a :Licensed Social Worker (LSW) for counseling and assessments. This service is provided by the One Way Farm and will work in conjunction with the Resident's medical team. The LSW will also be available for family counseling.
I request services to be provided for the Resident listed below:
Resident Name
Custodial Agency or Case Worker signature: Please use mouse to sign, phone or table please use finger
Medical History
Resident Name
Please type Resident Name
Date

MonthDayYear
Date
Has Resident been sick recently?

YesNo
Please explain sickness:
Does Resident have any allergies to food or medications?

YesNo
Please explain Allergies:
Is Resident currently taking any medications or drugs?

YesNo
Please explain medications or drugs:
Has Resident ever had any of the following conditions?

Rheumatic FeverScarlet FeverRheumatic heart diseaseHeart attackHigh blood pressureStrokeJaundiceDiabetesEpilepsyTuberculosisAsthmaHepatitisAnemiaSexually transmitted disease
Has Resident had any surgical procedure(s)
Please include date
Family History
Please list any illnesses in the family
Custodial Agency or Case Worker Signature. Please use mouse to sign, phone or tablet please use finger
Should be Empty:

Online Admissions Form

Resident's Registration Information

Medications

Activity Authorization Form

Counseling Services

Medical History