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Help For My Son

Welcome To

Application for Admission

Bald Eagle Boys Camp offers a unique and transformative experience for young men seeking to develop character, build leadership skills, and discover their true potential.

Registration Form

Dear Parent/Guardian:

Thank you for inquiring about Bald Eagle Boys Camp. We are encouraged by your concern and heartfor a young man who is struggling with life.

Enclosed is some information on Camp. If you feel that Bald Eagle Boys Camp may be what you are interested in, please complete the application. Return of the completed application does not necessarily mean you are committed to enrollment, but it does begin the process which may take 1-6 months. The next step of enrollment will be an interview with you in your home, along with your son, scheduled by a family worker from Camp. The purpose of this is to give more details about Camp’s program and to learn more about your situation. This will help all of us determine if Bald Eagle Boys Camp is suited for your son’s needs. If so, you will be invited to tour Camp and meet the group that is age appropriate for your son. It is then that the final decision will be made. If all are agreed, placement would occur within a week or two of the visits.

The per diem is $84.47. We understand this amount is prohibitive for almost all private placements. Call us to discuss a workable rate based on your income per month. We are a faith-based organization, and lack of finances will not be a determining factor for enrollment.

If you have any questions about the camping program or the application, please feel free to call our office at (570) 748-4543.

duane signature

Duane E. Fisher | Family Worker

DEF/kjo

Enc.

APPLICATION FOR ADMISSION

Seeking enrollment for:

First Name (Child’s) *

Last Name (Child’s) *

Middle Name (Child’s) *

Age *

Street Address *

City

State/Province

ZIP / Postal Code

Country

Person(s) with Custody:

Name *

Address *

Telephone *

Email *

Emergency Contact (other than custodian) *

Relationship to family *

Address *

Telephone *

Referred to Bald Eagle Boys Camp by:

Name

Telephone

Health Insurance Policies:

Company *

Policy Number *

Medicaid Number *

PARENTS and FAMILY

Father Detail:

First Name (Father) *

Last Name (Father) *

Telephone *

Address *

Education *

Marital StatusMarriedDivorcedSeparated

Date of Marriage *

Date of Birth *

Social Security Number

Religion *

Employer *

Occupation *

Address *

Telephone *

Work Hours *

Length of employment *

Monthly income *

Mother Detail:

First Name (Mother) *

Last Name (Mother) *

Telephone *

Address *

Education *

Marital StatusMarriedDivorcedSeparated

Date of Marriage *

Date of Birth *

Social Security Number

Religion *

Employer *

Occupation *

Address *

Telephone *

Work Hours *

Length of employment *

Monthly income *

Stepfather, Step-Mother, or Legal Guardian who lives with child:

First Name

Last Name

Telephone

Address

Education

Marital StatusMarriedDivorcedSeparated

Date of Marriage

Date of Birth

Social Security Number

Religion

Employer

Occupation

Address

Telephone

Work Hours

Length of employment

Monthly income

List child’s siblings (including step siblings):

Siblings Details

Name

Relationship *

Address *

Age *

FAMILY (continued)

List adults (other than parents or siblings) living in the child’s household:

Adults Details

Name

Age *

Relationship *

Who is child currently living with? (If different from parents)

Is child adopted?YesNo

If yes, please complete the following questions:

Name of Adoption Agency

Date Adoption was finalized

Child's age at adoption

Is child currently released for adoption?YesNo

Date released

Child

Birth date *

Weight *

Primary Language *

Height *

Country of Birth *

Hair Color *

State of birth *

Eye color *

Social Security #

Race *

Religion OR mark N/A *

List any scars, birthmarks, etc. that child has OR mark N/A *

Is child especially close to one parent or any other adult(s)? *YesNo

If yes, please explain. *

HEALTH AND DEVELOPMENTAL HISTORY

List any known physical disabilities and/or chronic conditions that the child has. *

Is child currently receiving medication? *YesNo

If yes, please list medication and reason for use. *

Has the child ever used alcohol or illegal drugs? If so, state when, how often and what type of drug was used. *

Give a history of known sexual activity, risky sexual behavior, or presence of venereal diseases. *

Has the child attempted to commit suicide, had suicidal thoughts, or caused self-injury? Y / N If yes, specify date of incidents, treatment given and conditions that seemed to cause these. *

Does child sleep well at night? *YesNo

If no, describe *

Does child wet his bed? *YesNo

If yes, how often? *

Describe any nervous habits child has (stuttering, nail-biting, etc.) *

LEGAL STATUS

Has child been arrested by police? If so, for what reason? *

Has child been involved with a court? *YesNo

If yes, for what offense? *

Has child been adjudicated dependant *

or delinquent *

Name and address of Court *

Court Counselor

Court documents pertinent to applicant

Upload file: Court documents pertinent to applicant

Drag and Drop (or) Choose Files

Order of Placement

Upload file: Order of Placement

Drag and Drop (or) Choose Files

SCHOOL

School child is currently attending *

Grade: *

Address *

Phone: *

Current School District *

Fax:

School previously attended (if applicable)

Address

Phone:

Previous School District

Fax:

Describe the child’s attitude towards school. *

If applicable, list suspensions or explusions

Does child have an Individualized Education Plan (IEP)? *

Date Implemented

Does child have current Evaluation Report (ER) given by school district? *YesNo

School

Date of (ER)

Has child been classified as emotionally disturbed by school psychologist? *YesNo

List any other psychological diagnosis

What recent events or behavior have caused you to seek placement at Bald Eagle Boys Camp? *

What goals are you seeking for the child by enrolling him at Bald Eagle Boys Camp?

What placement setting are you seeking for the child after his termination from Bald Eagle Boys Camp?ParentsFoster HomeGroup HomeIndependent LivingOther

Give number of prior placements. (Do not include placement in child’s own home or home of a relative.)

Institutional Group Care

Group Home Care

Emergency Home Care

Foster Family Care

Psychiatric Hospital

None

Please include the following information with application, if available.Current School Evaluation Report (ER)School Records/Current IEPCase and Social SummariesRecent photograph of child (dated)

Please give a biography of your child’s past and present behavior problems, including any life events related to these problems. Add additional sheets if necessary. *

Application completed by: *

Date *

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Group Living
Education
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Support Staff

Resources

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Application Process

Get In Touch

1077 Wilderness Trail, Mill Hall, PA 17751

Email: [email protected]
Phone: (570) 748-4543
Fax: (570) 371-5432

Facebook-f Youtube

Staff

Directors and Supervisors
Chiefs
Family Workers
Support Staff

Services

Therapeutic Camping
Group Living
Education
Family Involvement

Resources

Camp Information
Contact/Give
Privacy Policy
Enroll a Child

Get In Touch

1077 Wilderness Trail, Mill Hall, PA 17751

Email: [email protected]
Phone: (570) 748-4543
Fax: (570) 371-5432

Services

Therapeutic Camping
Group Living
Education
Family Involvement

Staff

Directors and Supervisors
Chiefs
Family Workers
Support Staff

Resources

Camp Information
Contact/Give
Privacy Policy
Enroll a Child

Get In Touch

1077 Wilderness Trail, Mill Hall, PA 17751

Email: [email protected]
Phone: (570) 748-4543
Fax: (570) 371-5432

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Help For My Son