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Child Application for a Life Book
Your Email Address:
Email Address to be sent TO:
I thought you may want to see this website. http://www.arizonansforchildren.org
Name of Person Completing Application:
Relationship to child:
Group Home Rep.
Other resources the child is receiving?
In-Home (with parent)
CPS Case Manager's Information
Arizonans For Children, Inc.
Child Profile for Life Book Program
Profile information is crucial to the effectiveness of our program and must be filled out completely with attached permission forms signed and submitted before child will be considered for tutor/mentor placement.
Child’s Full Name:
Has either of his/her parents ever been incarcerated:
Name of School:
Name of Teacher(s):
Teacher or School’s Phone #
How long has child been in state custody?
Reason for placement in state custody:
How long do you anticipate child will remain in state custody?
Can child make a one year commitment to participation in this program?
Does the child understand the concept of a Life Book and is he or she willing to participate?
Is the applicant currently seeing a counselor or therapist?
Any Prescription Medication:
Any Misdemeanor and/or Felony Convictions:
Is the child on probation?
Please give a brief description of child's interests, general demeanor and attitude:
Arizonans for Children, Inc.
of the following questions as completely as possible. If more space is needed, use an extra sheet of paper or write on the back of this page.
1. Why do you/your child want to participate in the Life Book Program?
2. Briefly describe your expectations for the Life Book Program:
3. Are the child and caregiver willing to attend an initial orientation session?
4. Does your child have friends? Please describe his/her friendships.
5. Name all services child is currently receiving (i.e. tutoring, CASA, mentoring programs)
6. Can you provide any additional background information that may be helpful in matching the applicant with an appropriate life book volunteer team?
Signature of Case Manager:
Printed Name of Case Manager:
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