Good News Boys Home Application - Good News Ministries

2024 Good News Boys Home 40-Day Summer Challenge

(Ages: 13-18) Monday, JUNE 10th, 2024 through Friday, JULY 19, 2024

The application includes 9 pages. Click Next when you reach the bottom of each screen. When you have completed the application, click Submit.

Are you also interested in our Academy Program*

Yes

No

CHILD'S BASIC INFORMATION

Upload Photo*

Max. file size: 1 GB.

Childs Name*

First Last

Date of Birth*

Current Age*

Please enter a number from 5 to 99.

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name*

Emergency Contact Number*

How did you hear about the Program?

ADDITIONAL INFORMATION

What do you see as the present problem concerning your child?*

Does your child consider himself to be*

LEGAL GUARDIAN INFORMATION

Legal Guardian #1*

First Last

Legal Guardian #2

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Phone

Email*

Email

Relationship to child*

Relationship to child

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

Group #

Policy #

File

Accepted file types: jpg, png, Max. file size: 1 GB.

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 all allergies

Comments

This field is for validation purposes and should be left unchanged.

2024 Good News Boys Home 40-Day Summer Challenge

(Ages: 13-18) Monday, JUNE 10th, 2024 through Friday, JULY 19, 2024

CHILD'S BASIC INFORMATION

EDUCATIONAL HISTORY

ADDITIONAL INFORMATION

LEGAL GUARDIAN INFORMATION

MEDICAL INSURANCE INFORMATION

Current Conditions and Medications

Links