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Referring Agency and Parent/Guardian Admissions Packet

After a youth is committed to George Junior Republic in Pennsylvania, it is required that the Admissions Packet be completed by both the Referring Agency and the Parent/Guardian.  The Referring Agency is responsible for completion of Forms 1 through 4.  The Parent/Guardian is responsible for completion of Forms 5 through 15.  Forms 16 and 17 are policies for review.   For your convenience, the forms are provided to you in four ways:  1)  one combined packet,  2) the Referring Agency Admissions Packet, 3) the Parent / Guardian Admissions Packet, or  4) as individual forms.   Please print and sign all forms. You may return them either by scanning and emailing them to [email protected]  or mailing them to the following address:

George Junior Republic in Pennsylvania
Admissions Office
233 George Junior Road
P. O. Box 1058
Grove City, PA 16127

Referring Agency and Parent/Guardian Combined Admissions Packet

Referring Agency Admissions Packet (includes Forms 1-4)

Referring Agency Admissions Packet - individual forms

FORM 1 - Youth information

form 2 - agency information

form 3 - family service plan

form 4 - barj notification and reconciliation

Parent / Guardian Admissions Packet - (includes Forms 5-17)

Parent / Guardian Admissions Packet - individual forms

form 5 - family information

form 6 - family visitation list and parent information guide acknowledgment

form 7 - student information consent / release

Form 8 - Educational Records Release

FORM 9 - youth participation consent / release

form 10 - medical and behavioral health coNSENT

form 11 - confidential health information consent / release

form 12 - outpatient behavioral health consent

form 13 - health history (2 pages)

form 14 - search and seizure and drug and alcohol testing

form 15 - safe crisis management and reflective time-out utilization parental notification and acknowledgment

form 16 - recommended clothing list

form 17 - no smoking / tobacco policy


 

 

 

 

 

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