2022 Good News Boys Home Summer Application

2023 Good News Boys Home Academy Summer School
Online Full Application
40-Day Summer Challenge:

Monday, JUNE 12th, 2023
through
Friday, JULY 21, 2023
Academy Spring Semester:

Monday, JAN 2nd, 2023
through
Friday, MAY 12th, 2023
Which program are you applying for?*

40-Day Summer Challenge9-Month Residential Academy
CHILD'S BASIC INFORMATION
Please Upload a full length picture of your child:*
Child's Name*

First Name Last Name
Date of Birth:*

MonthDay Year
Date
Current Age*
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Child's SSN:*
Emergency Contact Name:*
Emergency Contact Number*

Area Code Phone Number
How did you hear about the Program?

ADDITIONAL INFORMATION
What do you see as the present problem concerning your child?*
Has your child ever run away from home?*

YesNo
Does your child consider himself to be:*

HeterosexualBisexualHomosexualTranssexual
Does your child want to attend our program?*

YesNo
Are there any unusual factors in the students life of which we should be aware (deaths, separations, disabilities, accidents or illnesses of the resident or close relative, unusual living situations, etc)? Making us aware of these factors enable us to better understand and help your child. If no, type "No".*

MEDICAL INSURANCE INFORMATION
Hoosier Healthwise or Medicaid Number. If you have a different medical insurance provider, enter "N/A". *
If not Hoosier Healthwise, Name of Insurance company. If you have Hoosier Healthwise or Medicaid, enter "N/A". *
Insurance Company Phone Number

Area Code Phone Number
Group #:
Policy #:
Upload picture or copy of Medical Insurance Card

Browse Files
Cancelof

Current Conditions and Medications
Describe all current medical problems including treatments and medications.
Name of Condition or Disorder #1:
Names of medications and dosages for condition or disorder #1:
Name of Condition or Disorder #2:
Names of medications and dosages for condition or disorder #2:
Name of Condition or Disorder #3:
Names of medications and dosages for condition or disorder #3:
Name of Condition or Disorder #4:
Names of medications and dosages for condition or disorder #4:
Please list any other conditions, disorders, medications and dosages.
Does your child wear glasses or contacts?*

YesNo
Please list all allergies:

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CHILD'S BASIC INFORMATION