Please click here to download the application. When you have completed it please upload the file below and hit submit. If you can not do this please fill out the form below and submit it. If you do not know everything on the applicatoin please try and fill it out to the best of your ability and we can follow up with you to complete it.

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City, State, ZipCode:

 Male Female
Date of Birth:

Medicaid:  Yes No
Indigent:  Yes No
Case #:
Private Room:  Yes No
School Date:
School Location:
Are you bringing prescription medication(s)?  Yes No
Does client have any medical problems?
Describe pregnancy status of female clients:
Does client have any allergies that include food or drug reactions?
Does client have any special dietary requirements?
Does client have any other special needs?
Emergency contact number:
Physician and phone number:
Do you smoke?  Yes No

Additional Information