FORM 1

YOUTH INFORMATION

/
Youth Last Name Youth First Name / Date of Birth
/
County / Placing Agency / Social Security Number

1.  Description of factors resulting in referral for residential placement at this time. Include recent Court and/or Children and Youth involvement contributing to this request.

2.  State the goals and objectives of placement for this youth.

As a representative of the agency listed above and in lieu of a birth certificate available upon admission, I verify that the date of birth for the above-referenced youth is correct.

I also verify certification of placement and authorization of care of the above referenced youth at George Junior Republic in Pennsylvania. A court order specifying this will be forwarded to George Junior Republic in Pennsylvania upon receipt.

Signature of Agency Representative / Date
Printed Name of Agency Representative

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 2

AGENCY INFORMATION

Youth Last Name Youth First Name
County / Placing Agency

Dear Probation Officer / Caseworker:

It is important that the staff at George Junior Republic have access to your contact information and an emergency telephone number during evenings, weekends, and holidays. Please list contact information so that we may reach you after regular business hours.

Probation Officer / Caseworker:

County / Agency
/
Agency Representative / Direct Phone Number
/
Email Address / EMERGENCY Phone Number

In addition, George Junior Republic requires the information listed below for court purposes.

Judge / Courtroom (if applicable)

Public Defender / Child Advocate / Private Attorney:

Name / Agency
/
Email Address / Direct Phone Number

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 3

FAMILY SERVICE PLAN

Youth Last Name / Youth First Name
County
The above-referenced county Juvenile Probation Office Children, Youth, and Families Office
Community Umbrella Agency:

does complete youth Family Service Plans. A copy of the most recent Family

Service Plan is attached for George Junior Republic’s record. Reviews will be

forwarded to George Junior Republic when completed.

does not complete youth Family Service Plans.

Agency Representative Signature:

Signature / Date
Print Name

Caseworker Signature:

Signature / Date
Print Name

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 4

BARJ NOTIFICATION AND RECONCILIATION

Youth Last Name Youth First Name
County/Placing Agency

RESTITUTION

(If more than one agency is owed, please copy form and complete.)

Attention: / TOTAL Costs and Fines owed
Payable to (Agency):
Address:
Phone: / / /

COURT COSTS / FINES

Attention: / TOTAL Costs and Fines owed
Payable to (Agency):
Address:
Phone: / / /

COMMUNITY SERVICE

Attention: / TOTAL Hours owed
Business / Agency
Address:
Phone: / / /

Please attach any available supporting documentation (court order, court dictation, etc.) that shows the details and amounts owed and mail back to GJR in the enclosed envelope or fax to 724-458-8401. If you have questions or need updated information, please contact Matthew Louise at 724-458-9330 x3131.

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 5

FAMILY INFORMATION

Youth Last Name Youth First Name
Legal Guardian’s Name if other than Parent

FATHER – Have parental rights been terminated by order of the Court? Yes No

/ /
Father’s Name / Cell Phone
/ /
Place of Employment / Work Phone
/ /
Current Home Address / Home Phone
Date of Birth / / / School Grade Completed / Marital Status / Single Married Divorced

MOTHER - Have parental rights been terminated by order of the Court? Yes No

/ /
Mother’s Name / Cell Phone
/ /
Place of Employment / Work Phone
/ /
Current Home Address / Home Phone
Date of Birth / / / School Grade Completed / Marital Status / Single Married Divorced

PATERNAL GRANDPARENTS MATERNAL GRANDPARENTS

Name / Name
Address / Address
/ / / / /
Phone Number / Phone Number

OTHER RELATIVES

YES NO
Name / Relationship / Resides with Client
YES NO
Name / Relationship / Resides with Client
YES NO
Name / Relationship / Resides with Client

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 6

FAMILY VISITATION LIST AND PARENT INFORMATION GUIDE ACKNOWLEDGMENT

Youth Last Name Youth First Name
County / Placing Agency

Please list those BIOLOGICAL RELATIVES or GUARDIANS permitted visitation and his/her relationship to your child. Keep in mind that visitation cannot begin until this form is returned and only four (4) people are permitted to visit at one time.

NAME / RELATIONSHIP

As the parent / guardian of the above-referenced child, I acknowledge by my signature below I have received and reviewed George Junior Republic’s Parent Information Guide and understand the Child Rights and Youth and Family Grievance policies.

Parent / Guardian Signature / Date
Agency Representative Signature / Date

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 7

STUDENT INFORMATION CONSENT / RELEASE

George Junior Republic (“GJR”) and its affiliates (GJR in PA, GJR in Indiana, and Preventative Aftercare) periodically publish or otherwise make publicly available the names, images, likenesses, voices, achievements and/or recognizes or provides similar information about students or their activities at or relating to George Junior Republic (“Personal Information”) for the purposes described below. These releases of information include but are not limited to: press releases, newsletters, photographs, videos (including voices), recordings, fundraising materials, “broadcasts” or other information dissemination provided as, on, or in television, radio, computers, phones, social media, blogs, podcasts, mobile devices or apps, the GJR website, other websites or online services, and other existing or future ways to release information.

Purposes. The releases are made for purposes of supporting, advertising, raising funds, educating, or otherwise promoting or providing information about George Junior Republic or its mission, programs, students, community activities, or outreach efforts. The releases may be provided locally, nationally, or internationally and in all possible existing or future media (now known or unknown).

By my signature below, I (a) certify that I have (or have obtained) all necessary permissions and authority lawfully to provide this consent so that it will be legally binding, and (b) give consent for George Junior Republic (and its representatives, agents, and service providers) to publish and/or release the Personal Information about the student identified below for the limited purposes described above, all without payment to the student, me, or anyone else. I understand that I may withdraw this consent by writing George Junior Republic at 233 George Junior Road, Grove City, PA 16127, but agree for myself and the student that any withdrawal will not be effective as to anything already published or when GJR has already relied upon this consent.

/
Name of Student (print) / Student Date of Birth
Name of Signing Parent/Guardian, Adult Student, or Authorized Representative (print) / Signer’s Relationship to Student
SIGNATURE (sign legal name and include any necessary title or authority) / Date

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 8

EDUCATIONAL RECORDS RELEASE

I hereby authorize the appropriate school official or designated representative of the Grove City Area School District to obtain educational records for the following student:

/
Student Last Name Student First Name / Date of Birth

RELEASE INFORMATION TO:

Email Address: OR Mailing Address:

Ruthe Malumphy, Guidance Secretary George Junior Republic School

Attention Guidance Secretary

233 George Junior Road

Grove City, PA 16127

Contact Jim Anderson, Principal, George Junior Republic School, at 724-458-9330 x3701 or with any questions or concerns.

Signature of Parent / Guardian / Student (if 18 years of age or older) / Date
Printed Name of Parent / Guardian / Student (if 18 years of age or older)

Please provide me a copy of the released information: No Yes - indicate Email or US mail and complete below

Email Address:
Mailing Information:
Printed Name of Parent / Guardian / Student (if 18 years of age or older)
Street Address
City / State / Zip Code

FOR OFFICE USE ONLY Email US mail

Date Released: / Released by:

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 x2100 · Fax: 724-458-8401

FORM 9

YOUTH PARTICIPATION CONSENT / RELEASE

Youth Last Name Youth First Name
County / Placing Agency

CHECK ALL THAT APPLY

I hereby give my permission for my son to engage in the religious practices of his choice while at George Junior Republic in Pennsylvania.

I hereby give my permission for my son to engage in recreation activities of his choice while at George Junior Republic in Pennsylvania.

I hereby give my permission for my son to engage in athletic programs of his choice while at George Junior Republic in Pennsylvania.

My son is permitted to wear his watch, have his radio/stereo, his electric razor, or any other personal property under the condition that George Junior Republic in Pennsylvania is not responsible for anything that happens or may happen to the above-mentioned objects.

I hereby give permission for my son to receive Driver’s Education instruction at George Junior Republic in Pennsylvania, as well as give permission to Richard L. Losasso, Chief Executive Officer, to sign as the Person in Loco Parentis on the official Parent or Guardian Consent Form used to obtain a Pennsylvania Driver Learner’s Permit.

Parent/Guardian Signature / Date

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 10

MEDICAL AND BEHAVIORAL HEALTH CONSENT

Youth Last Name Youth First Name
/ /
County / Placing Agency / Date of Birth

1.  I hereby give permission for my child to be provided routine health care while in placement at George Junior Republic. I understand routine health care to mean child health examinations, dental care, vision care, hearing care, treatment for injuries and illnesses, and routine immunizations.

2.  I understand that a separate written consent must be obtained from the parent, legal guardian, or if the parent or legal guardian cannot be located, by Court Order, for each incident of non-routine treatment such as elective surgery or experimental procedures.

3.  I understand that if my child needs emergency psychiatric / medical care or treatment for a life threatening condition, consent is not required. If my child needs emergency medical care or treatment, medical personnel does not need consent to provide treatment in life threatening conditions.

4.  I understand that my child will be provided behavioral health care services on an ongoing basis as defined in his treatment plan. I understand that behavioral health care services may include individual, group, or family therapy as well as psychological or psychiatric interventions. I understand if my child is under the age of 14 years, he will not be provided behavioral health medications without my consent. I understand such care will be provided by an appropriate level of mental health care worker. I understand that I have a right to refuse behavioral health care at any time by notifying, in writing or verbally, George Junior Republic. In addition, George Junior Republic may terminate behavioral health care services by notifying me or my child, verbally or in writing, of the reasons for termination and that George Junior Republic will refer my child for alternative treatment services if requested or required.

5.  I understand this consent is applicable for my child to receive medication services if deemed appropriate. The benefits and side effects of medications and/or medication changes will be explained to me and/or my child during the medication services.

Parent / Guardian Signature
(parent or guardian must sign if youth is under the age of 14 years) / Parent / Guardian - Print Name / Date

233 George Junior Road · P.O. Box 1058 · Grove City, Pennsylvania 16127 · 724-458-9330 Ext. 2100 · Fax: 724-458-8401

FORM 11

CONFIDENTIAL HEALTH INFORMATION CONSENT / RELEASE

Youth Last Name Youth First Name
Agency Releasing Information

I do hereby consent to authorize the above-referenced agency to disclose information to George Junior Republic in Pennsylvania, 233 George Junior Road, P. O. Box 1058, Grove City, PA 16127, pertaining to my care:

Presence in treatment, including admission and discharge date Treatment Plan

Diagnosis, brief description of progress and prognosis Biopsychosocial Assessment

Medical history and physical Discharge Summary

Psychiatric / psychological reports Continuing Care Plan

Other:

This information is needed for the following purposes:

To provide ongoing treatment / continuing care

To enable judges, attorneys, and probation / parole officers to support treatment goals and make legal decisions on my behalf

Other:

I understand that George Junior Republic must comply with multiple statutes and regulations relating to confidentiality of records and the information above cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I need not consent to the release of information in order to obtain treatment services. I choose to do so willingly and voluntarily for the purposes specified above. This consent is effective on the date of my signature and expires automatically in one year from that date unless I specify a date, event, or condition upon which it will expire sooner. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. (Specify date, event, or condition upon which this consent will expire sooner.)

NOTICE TO RECIPIENTS OF INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by Federal and State statutes. Regulations limit your right to make further disclosure of this information without prior written consent of the person to whom it pertains.