Run 2 Rescue Rebuild & Restore Hope
Application
Today's Date
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Month
-
Day
Year
Date
Parent/Guardian Personal Information
Parent/Guardian
*
Please Select
Biological Mother
Biological Father
Biological Grandmother
Biological Grandfather
Biological Aunt
Biological Uncle
Foster Mother
Foster Father
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Staus
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Married
Divorced
Single
Custody of Youth
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Please Select
Joint
Primary Mother
Primary Father
Full Mother
Full Father
DPSS
Probation
Other
Language spoken in household?
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Emergency Contact: Name
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Emergency Contact: Phone Number
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Please enter a valid phone number.
Best time to reach you
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Morning
Afternoon
Evening
Parent/Guardian Background
Last completed school grade?
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Current Job:
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Have you taken in another youth before?
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Please Select
Yes
No
Interest/Hobbies
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Specialized skills or training?
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Have you had military service?
*
Please Select
Yes
No
Date of service or discharge?
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Month
-
Day
Year
Date
Do you have a weapon in your home?
*
Please Select
Yes
No
If yes, please list what.
Nearest Hospital to resident and how long it would take to get there?
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What recreation facilities are near the home what is the distance?
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Are you willing to be trained to handle the youth and their trauma?
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Please Select
Yes
No
Do you have support to help you with the youth other than R2R?
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Please Select
Yes
No
Dwelling type
How many bedrooms & bathrooms?
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Any other residents in the home?
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If yes, residents names, DOB and relation to the youth
How long have you lived at your current residents?
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Will the youth have their own space/bedroom?
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Please Select
Yes
No
Who will be home durning the day to be with the Youth?
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Will you be able to handle the trauma that comes with the youth?
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Please Select
Yes
No
Other
Where will the youth be when you are unable to be with the youth?
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What are some concerns you have with the youth coming back home?
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Have you read the Rebuild & Restore Hope program Rules?
*
Please Select
Yes
No
Do you agree to abide by the Rebuild & Restore Hope program Rules?
*
Please Select
Yes
No
Do you understand that not following the the rules means Run 2 Rescue will remove the Rebuild & Restore Hope program from the home?
*
Please Select
Yes
No
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Youth Personal Information
Please add a recent picture of youth
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Youth Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Biological Gender
*
Please Select
Male
Female
Primary Location
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What school district is the youth?
*
Current School Year
*
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Youth's Medical Provider
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Youth's Medical ID Number?
*
Has the youth been diagnosed with mental health?
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Yes
No
If yes please list diagnoses
Is the youth on medication
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Yes
No
If yes please list medication
Drug History (if ever used, please check all that apply)
*
Marijuana
Cocaine
Crack
Heroin
Meth
Ecstasy
Alcohol
Acid
Xanax
Fentanyl
Other
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Current Situation
Briefly describe current situation
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Has there been any sexual exploitation (i.e.molestation, rape, online solicitation)
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Has there been any physical abuse? (if yes please explain)
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History of hospitalizations (if yes please explain)
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Is there a history of running away (if yes please explain)
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How is the youth in school and around other youth (i.e. other kids at school or in the home)
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