2022 Good News Boys Home Summer Application

Good News Boys Home 2023-2024 Academy Application

Program Dates:

August 14th, 2023 -
May 10th, 2024
Thank you for your interest in Good News Boys Home! We accept a limited number of male applicants ages 14-18 for our free 9-month Academy program. Please complete the 9-page application below.
CHILD'S BASIC INFORMATION
Please Upload a full length picture of your child:*
Child's Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Current Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's SSN:*
Emergency Contact Name:*
Emergency Contact Number*

Area CodePhone Number
How did you hear about the Program?

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 CodePhone 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