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NEW ENGLAND KURN HATTIN HOMES WESTMINSTER, VT 05158 (802) 722-3336, EXT. 132 FAX (802) 722-3174 www.kurnhattin.org APPLICATION FOR ADMISSION

Today’s Date _______________ How did you hear about Kurn Hattin? ______________________ Child’s Full Name ____________________________ Age __________ Date of Birth _____________ Sex ________ Place of Birth _____________ Social Security Number of Child __________________ Person with legal custody _______________________ Their Marital Status ____________________

Address ______________________________________________ Phone (___)_________________ Relationship to child ______________________ Is child living with this person? (yes or no) ________ If not, name and address of person child is living with ______________________________________ Is child adopted? � yes � no If yes, does child know?_____________________________________ Current or most recent school ________________________________ Phone (___)______________ Address _________________________________________________________________________ Grade (If school’s out, grade child starts in Sept.)___ Any grades repeated? ____ Which one(s)? ___ Does your child have health insurance? � yes � no If yes, name of insurance company (Medicaid, Mass Health, Blue Cross/Blue Shield, etc.). Name of Insurance Company _________________________________________________________ Name of policy holder _______________________________________________________________ Insurance Co. Policy Number _______________________________Phone Number (___)__________________ Insurance company address: ________________________________________________________ ________________________________________________________________________________ Kurn Hattin’s policy is that every child attends religious services Sunday morning unless alternative arrangements for their supervision are made by their family. We provide transportation to Catholic and Protestant churches. If you prefer your child attend services elsewhere, or not at all, it will be your responsibility to make arrangements for transportation and supervision. I would like my child to attend � Protestant services � Catholic services � Other, which I will arrange.

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FAMILY 1. Father. Is he living? � yes � no (if no, date of death _________________________________)

Name _________________________________ Date of Birth ____________ Age _________

Address _____________________________________________ Phone (___)______________

Place of work ______________________Work phone (___)___________ Work hours _______

Occupation _______________________________ Highest grade completed in school _______

2. Mother. Is she living? � yes � no (if no, date of death _______________________________)

Name __________________________ Date of Birth __________________ Age _______

Address _____________________________________________ Phone (___)______________

Place of work _____________________Work phone (___)___________ Work hours ________

Occupation _________________________________ Highest grade completed in school ______

3. Brothers & Sisters

Name Date of Birth Age Sex Place where living

4. Other children living in child’s current home.

Name Age Sex Relationship to child

5. Adults living in child’s current home that have not yet been listed on this form. (stepparents, etc.)

Name Age Sex Relationship to child Occupation

6. Other important adults in child’s life (grandparents, mother’s boyfriend, father’s girlfriend, etc.).

Name ___________________________________Relationship to child _____________ Age ______

Address____________________________________________ Phone (___)___________________

Name ___________________________________Relationship to child ______________Age ______

Address__________________________________________ Phone (___)_____________________

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YOUR CHILD 1) Behavior – Rate each of the following 0-Never 1-Rarely 2-Sometimes 3-Often

My child: yells and swears _______ hits other children __________ hits adults _________

hurts him/herself ________ throws or breaks things _______ runs away _______ Please explain: _________________________________________________________________ ________________________________________________________________________________ 2) How did your child react when told about the possibility of going to Kurn Hattin? ______________ ________________________________________________________________________________ ________________________________________________________________________________ 3) Tell us some good things about your child. ___________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 4) Has your child ever gone to a counselor, therapist or psychiatrist? � yes � no Who? _________

Address_______________________________________ Phone (___)______________________ Was it helpful? _________________________________________________________________

______________________________________________________________________________

5) Has there ever been involvement with other agencies such as SRS (VT), DSS (MA), DCYF

(NH)?

� yes � no Name of Agency ___________________________________________________ Please describe why, when, and what happened. _____________________________________ ________________________________________________________________________________ 6) Has your child spent time away from you? _____ If yes, how long, where, and when? ________ ________________________________________________________________________________ ________________________________________________________________________________ 7) Has your child ever been suspended from school? � yes � no Involved with the police or adjudicated? � yes � no Please explain: ________________________________________________________________ ________________________________________________________________________________

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Describe child’s family situation, relationships and behavior. Why are you applying to Kurn Hattin? What changes do you and your child hope to see in your child and family? (Please feel free to use more paper) Do you (parent/guardian) speak English? � Yes � No � Some Name of person(s) filling out application ________________________________________________ Relationship to child ________________________________________

PERMISSION TO RELEASE INFORMATION I, __________________________________________, am the legal guardian of the above named child and have applied for his/her admission to New England Kurn Hattin Homes. I therefore authorize release of all records necessary for this process. I understand that all application materials will be kept confidential by Kurn Hattin and no personally identifiable information about my child will be released without my permission. Signature of Legal Guardian ____________________________________