Parent Information (if deceased please note date and cause)
Please give the following information of each immediate member of your family
Persons to notify in case of emergency
Social History Please describe the personality of your child in the following phases.
Family Relationships (please describe your child's relationship with family members)
If your child has ever run away, please answer the following questions:
History of Abuse: (Sexual, Physical and Emotional)
Specific History of Abuse
Please list all who have examined or treated your child: (Physicians, Psychiatrist, Psychologist, etc.)
To adequately understand the parent/child relationship and its impact on the child, it is very important that we know of any family therapy. Please list all psychiatric, psychological and/or marriage and family therapy that the family members have participated in:
What are your child's special needs and strengths in the following areas?
Please describe your child's performance (grades, relationship with teachers, behavior, etc.)
Legacy Boys Academy14240 S 575 RD Stockton, MissouriPhone: 417-955-1859Fax: 417-809-8622Email: firstname.lastname@example.org
The parents of have requested that his records be transferred. Please release an Official transcript, birth certificate (copy), immunization record, and a description of subjects and a grading scale to the receiving school named above.
Child’s Age: Birth Date: Releasing School’s Name: Address: Sincerely,Brent Jackson, RegistrarFor office use only,Date of Arrival: / / Date of Mailing: / / Please include a copy of the student’s birth certificate and immunization records with the orientation paperwork. Please notify the Legacy office if the student’s former school will send that paperwork.
Legacy Boys Academy Authorized MedicinesStudent Name: First Name Last Name Birth Date: Date I First Name Last Name give my permission to the agents of the above institution to disperse over-the-counter medicines listed below to my son on an as-needed basis. I also give permission to the above mentioned institution to disperse any prescription medicines that are prescribed by a doctor for my son and in my son’s name.Legacy Boys Academy provides supervised use of the following medications at no cost: Ibuprofen Pepto Bismol Tylenol Anti-diarrheal Medicidin D Campho-Phenique Sudodrin Dramamine Cold Relief Chloraseptic Spray Benadryl Mylanta If you object to the use of any or all of the above over-the-counter medicines, or if your son is allergic to any medicines, please list in comments below.Comments:Parent/guardian Signature Date I do NOT want my son’s medical information released to the following individuals/organizations: This list is for those that you specifically do not want receiving medical information about your son. For example, if you do not want us to release information to grandparents, stepparents, etc.