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
MOTHER - Have parental rights been terminated by order of the Court?
/
Single
Married
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
PATERNAL GRANDPARENTS
MATERNAL GRANDPARENTS
Name
Name
Address
Divorced
/
Married
Divorced
Address
/
/
Phone Number
/
/
Phone Number
OTHER RELATIVES
Name
Relationship
YES
NO
Resides with Client
Name
Relationship
YES
NO
Resides with Client
Name
Relationship
YES
NO
Resides with Client
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:
Ruthe Malumphy, Guidance Secretary
[email protected]
OR
Mailing Address:
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
[email protected] 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
FOR OFFICE USE ONLY
Date Released:
Zip Code
Email
US mail
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 / Guardian - Print Name
Date
Witness – Print Name
Date
(parent or guardian must sign if youth is under the
age of 14 years)
Witness Signature
I understand that this consent form will be sent to my parents or guardian for signature. I have been offered a copy of this
form and I
accepted
declined (also initial)
Youth Signature
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
Diagnosis, brief description of progress and prognosis
Medical history and physical
Psychiatric / psychological reports
Other:
Treatment Plan
Biopsychosocial Assessment
Discharge Summary
Continuing Care Plan
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.
I have been offered a copy of this form and I have
accepted
declined.
(also initial)
Student Signature
Date
Parent/Guardian or Authorized Representative Signature
Date
Witness Signature
Date
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401
FORM 12
OUTPATIENT BEHAVIORAL HEALTH CONSENT
/
Youth Last Name
Youth First Name
/
Date of Birth
County / Placing Agency
1. I understand that my child will be provided outpatient behavioral health services on an ongoing basis as defined in his
treatment plan. I understand that behavioral health 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 professional. I understand that I have a right to refuse behavioral health care at
any time by notifying, in writing or verbally, George Junior Republic Outpatient Program staff. In addition, George
Junior Republic may terminate behavioral health services by notifying me or my son, in writing or verbally, of the
reasons for termination, and George Junior Republic will refer him for alternate treatment services if requested or
required.
2. I understand this consent is applicable for my son 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 son during the
medication services.
3. I understand that consent for emergency psychiatric / medical care or treatment is not required. If a child needs
emergency medical care or treatment, medical personnel do not need consent to provide treatment in life
threatening conditions.
Parent / Guardian Signature
Parent / Guardian - Print Name
Date
Witness – Print Name
Date
(parent or guardian must sign if youth is under the
age of 14 years)
Witness Signature
I understand that this consent form will be sent to my parents or guardian for signature. I have been offered a copy of
this form and I
accepted
declined (also initial)
Youth Signature
Date
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401
FORM 13 Page 1
HEALTH HISTORY
Youth Last Name
Youth First Name
/
/
Date of Birth
County / Placing Agency
Having accurate medical background information at the time of admission assists our medical staff in planning and
providing the best possible care for each youth. Please complete this form. Include the names and telephone numbers
for all medical/dental providers who continue to provide specialized care for the above-referenced youth.
Family Health History: Please check below if the grandparents, aunts/uncles, parents, or siblings have the following
health conditions:
diabetes
heart disease
stroke
asthma
hepatitis
sickle cell disease / trait
HIV infection
cancer
heart attack
blood clots
seizures / epilepsy
high blood pressure
depression
death by suicide
tuberculosis
thyroid disease
alcohol / drug addiction
 Other:
Youth Health History: Please check all that apply.
asthma
seizures / epilepsy
chicken pox
hearing problems
suicide attempt(s)
diabetes
heart condition
vision problems
speech problems
injuries (explain below)
enuresis (bed wetting)
loss of bowel or bladder control
headaches, migraines
depression
surgery (explain below)
No known allergies
Allergies to the following medications:
Allergies to the following foods:
Other allergies:
CURRENT MEDICATIONS
Name of medication
Daily dosage/times given
Reason for taking
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401
FORM 13 Page 2
YOUTH LAST NAME, FIRST NAME
INSURANCE INFORMATION
Primary Insurance Name
Policy / Agreement #
Group #
Name of Policy Holder:
Secondary Insurance Name:
Policy / Agreement #
Group #
Name of Policy Holder
Coverage
Employer:
Coverage
Employer:
Is youth currently receiving state medical assistance?
Yes
No
Under the Pennsylvania Department of Human Services Guidelines, the following immunizations are required by
all children, grades K-12:
4 doses of diphtheria (1 dose on or after the 4th
birthday)
2 doses of varicella (chickenpox) or evidence of
immunity
3 doses of polio
3 doses of hepatitis B
2 doses of measles
1 dose of rubella (german measles)
7th Grade ADDITIONAL requirements for every child include:
1 dose of meningococcal conjugate vaccine (MCV)
1 dose of tetanus, diphtheria, acellular pertussis (Tdap) IF five (5) years have passed since the last tetanus
immunization was given.
Please attach a copy of the youth’s immunizations with this Health History form. If you do not have this information,
list the name, city, and state of the public school the youth most recently attended.
Name of School
City State Zip
Please note below the names, phone numbers, and treatment provided for any medical, dental, psychiatric, or other
health provider who recently cared for this youth.
Name
Phone Number
/
/
/
/
/
Treatment Provided
/
/
/
/
/
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401
FORM 14
SEARCH AND SEIZURE
AND
DRUG AND ALCOHOL TESTING
Youth Last Name
Youth First Name
County / Placing Agency
It is the policy of George Junior Republic to conduct drug and alcohol testing and searches of youth for
seizure of illegal or dangerous items. Youth in the residential program will be drug tested after home
passes, at the order of the court or request of the placing agency, and randomly if there is reasonable
suspicion of chemical abuse. Likewise, youth returning from a home pass will be searched and any illegal
or dangerous items will be confiscated.
All searches and seizures and drug testing will be conducted within a controlled environment and with
the permission of an administrative staff member. Please refer to the attached policies and procedures
regarding these two issues prior to signing this form.
I understand that as part of the residential program, George Junior Republic will conduct drug and
alcohol testing and searches and seizures as explained in the policies and procedures. I consent to drug
and alcohol testing and to search and seizure as George Junior Republic deems necessary.
Student Signature
Date
Parent / Guardian or Authorized Representative Signature
Date
Placing 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 15
SAFE CRISIS MANAGEMENT AND REFLECTIVE TIME-OUT UTILIZATION
PARENTAL NOTIFICATION AND ACKNOWLEDGMENT
Youth Last Name
Youth First Name
County / Placing Agency
Safe Crisis Management at George Junior Republic dictates that restrictive procedures may only be used when all other
attempts to anticipate and de-escalate a resident’s behavior have occurred and the resident presents a physical danger
to himself and/or others. The policy of George Junior Republic is to use Emergency Safety Physical Interventions, also
known as physical restraints, as measures of last resort to ensure the safety of all youth and our staff. The use of verbal
and non-verbal de-escalation techniques, such as reducing stimuli, providing a quiet, comfortable space, reflective
listening to resident concerns, and/or allowing an outlet for physical energy will be utilized by trained staff.
Restrictive procedures will respect the dignity of residents and will only be used by trained staff. A physical restraint is
defined as application of physical force by one or more individuals that restricts or reduce a resident’s ability to move his
arms or legs freely. They are used to interrupt a resident’s behavior when it becomes dangerous to him or others and in
order to help him regain personal control. George Junior Republic supports self-management by helping residents
develop skills and supports to appropriately manage their own behavior in stressful times. By building on these skills,
residents will be involved in fewer situations that require staff to intervene thus reducing the use of Emergency Safety
Physical Interventions. However, if a resident does become a danger to self or others and the behavior cannot be deescalated, then George Junior Republic staff will use these techniques to protect the resident and others.
Additionally, George Junior Republic staff may place a resident in Reflective Time-Out, defined as restriction of a
resident for a period of time in a designated area from which the youth is not physically prevented from leaving. The
purpose is to provide the resident the opportunity to regain self-control. At least one staff member is present to directly
supervise the resident during this time.
As the parent or guardian of the above-referenced resident, I have read and understand the use of Safe Crisis
Management and Reflective Time-Out as explained above. I further understand that should my child need to be
protected from harming self or others, George Junior Republic staff will utilize Reflective Time-Out and Emergency
Safety Physical Interventions to ensure his safety. I also acknowledge that I have been given the opportunity to ask
questions regarding Safe Crisis Management in order to make an informed decision as evidenced by my signature.
Parent / Guardian Signature
Date
Witness Signature
Date
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401
FORM 16
RECOMMENDED CLOTHING LIST
The following items of clothing, in good condition, are necessary for each youth upon
admission to George Junior Republic. Usually, youth wear clothes similar to what they would
wear or should wear in their community. Designer clothing, shoes, watches, and jewelry ARE
NOT permitted. Personal items, including clothing, will not be replaced if lost, stolen, or traded.
PANTS
1 pair dress pants (e.g., Dockers, Khakis)
5 pair jeans
2 pair shorts
SHIRTS
10 casual shirts such as button shirts, polo style shirts, pocket T-shirts, or design T-shirts
UNDERCLOTHING
9 pair briefs or boxers
SOCKS
9 pair socks
SHOES
2 pair tennis shoes
1 pair boots
OUTDOOR WEAR
1 light jacket or hooded sweatshirt
2 sweatshirts
1 winter coat (seasonal - October through April)
1 pair winter gloves (seasonal)
1 winter hat (seasonal)
ACCESSORIES
1 belt
Revised 03-15
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401
FORM 17
NO SMOKING/TOBACCO POLICY
In accordance with the following law, George Junior Republic has a no smoking / tobacco policy for
youth in placement. Youth are not permitted to smoke or use tobacco products of any kind. George Junior
Republic does not sell tobacco on our campus and staff members are not permitted to purchase or supply
youth with tobacco while in placement. Parents, guardians, or visitors are not permitted to provide
residents with tobacco products of any kind, including electronic cigarettes.
Pennsylvania State Law #6505 regarding the sale of tobacco is as follows:
Section 6305. Sale of tobacco.
(a) Offense Defined. A person is guilty of a summary offense if he:
1. Sells tobacco, in any form, to any minor under the age of 18 years;
2. By purchase, gift or other means, furnishes tobacco, in any form, to a minor under
the age of 18 years; or
3. Knowingly and falsely represents himself to be 18 years of age or older to another
for the purpose of procuring or having furnished to him tobacco in any form.
(b) Penalty. A person who violates this section shall, upon conviction be sentenced to pay a
fine of not less than $25.00 for a first offense and not more than $100.00 for a subsequent
offense.
Section 3. This act shall take effect immediately.
Approved February 14, 1990.
Revised 03-15
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401