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Referring Agency and Parent/Guardian Admissions Packets

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  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