APPLICATION FOR ADMISSION

APPLICATION FOR ADMISSION

7200 DeSiard St - Monroe, LA 71203 | 318-343-4445
Please answer all questions completely. All information is kept confidential.
Full Name*

First NameMiddle NameLast Name
Other Names

Maiden NameOther Names Used
E-mail
example@example.com
Phone Number*
Please enter a valid phone number.
Is it safe to text or leave a message?*

YesNo
Date of Birth*
AGE*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Social Security Number*
Driver's License/State ID #*
If you have a DL, is it suspended?*

YesNo
Are you a US Citizen?*

YesNo
Marital Status*

MarriedNever MarriedDivorcedSeparatedWidowedReconcilingIf reconciling, please explain below
Spouse Full Name
Describe your relationship with your spouse:
What are the child custody/visitation arrangements? (if none, type none):*

Previous Marriages

	Spouse Name	Marriage Date	Divorce Date
Marriage 1
Marriage 2

Parent and Child(ren) Status

Please answer all questions to the best of your knowledge.
Do you have any other children that are not listed on this form?*

YesNo
Are you pregnant?*

YesNo
If yes, due date:
Are you seeing a doctor?*

YesNo
If yes, doctor's name:
Are you or have you been involved with DCFS/CPS?*

YesNo
If yes, when & please, explain:
Describe how your children get along with friends/teachers at school.
Describe your children's personality and behavior.
Describe your relationship with your children.
How do your children feel about the idea of coming into this program?
Other comments about your children:
List Previous address (beginning with most recent). Include complete address, dates you lived there, and reason for moving.

List 3 References: (Only use 1 family member & 1 friend. Others may include coworkers, landlords, ect.)*

List employment beginning with most recent.

HomePlace Application Agreement
The information contained in the application is correct to the best of my knowledge. I understand that making false statements or being untruthful at any time will result in termination of LBCHFM services.
Signature*

Clear
By signing this document, I understand the statement above.
Should be Empty: