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Child Application for a Life Book
Program Request:
Referral Source Date:
Name of Person Completing Application:    
Agency Name: Title:
Phone Number: Cell Phone:
Relationship to child:
Foster Parent Case Manager Relative (explain):
Group Home Rep. Shelter Rep. Other(explain):
Child's Information
Full Name: Other resources the child is receiving?
Age: DOB:
Gender: Ethnicity:
Address: City:
ST: Zip:
Placement Type: Foster Home Group Home Shelter In-Home (with parent) other:
Caregiver Information
Name: Relationship:
Phone: Cell Phone:
Address: City:
ST: Zip:
CPS Case Manager's Information
Name:
Phone: Alternative Phone:
Agency: Address:
Email Address: Fax Number:
Arizonans For Children, Inc.
Child Profile for Life Book Program
Please Note: 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: Nickname:
Has either of his/her parents ever been incarcerated:
Name of School: District:
Name of Teacher(s): Grade:
Teacher or School’s Phone # Room #
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? Yes No
Therapist’s Name:
Behavioral Issues:
Health Issues:
Any Prescription Medication:
Any Misdemeanor and/or Felony Convictions: please explain:
Is the child on probation?
Please give a brief description of child's interests, general demeanor and attitude:

Arizonans for Children, Inc.
Interest Survey
Please answer all 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: Date:



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