2019 Good News Boys Home Summer Application

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

Yes No
Does your child consider himself to be: *

Heterosexual Bisexual Homosexual Transsexual
Does your child want to attend our program? *

Yes No
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

Cancel of

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? *

Yes No
Please list all allergies:

CHILD'S BASIC INFORMATION