Family-Focused Care Application

Family-Focused Care Application
NOTE: This application is for MOTHERS WITH CHILDREN. If you need to place a child age 6-17 into child-focused residential care, please use this form instead: http://bit.ly/OBHC-ChildApp. Thank you.
General Information
Location Preference

By checking your placement location preference below we will know how to best direct your application.
Which location would you prefer?*

Family Focused Care at BCH (Owasso)Family Focused Care at The Vine (OKC)No Location Preference / First Available (Submits to both locations.)
Name*

First NameMiddle (optional)Last Name
Date of Birth*

MonthDayYear
Age*
(Adult applicant)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Phone Number*
Contact Phone Description*

HomeWorkCellFriend
Email*
example@example.com
Spouse/Boyfriend
Describe your relationship with your spouse/boyfriend/child's father:*

Education/Work History

(Adult Applicant)
Education
Grade in School Completed*
Do you have a G.E.D., high school diploma or college diploma?*

YesNo
Work History
Have you ever been employed?*

YesNo
Most Recent Job
Business Name - Most Recent Job
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number
Supervisor Name
Dates Employed
If exact dates aren't known, please provide month and year.
Position
Hourly Wage/Yearly Salary
Monthly Pay
Reason for Leaving
Previous Job
Business Name - Previous Job
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number
Supervisor Name
Dates Employed
Position
Hourly Wage/Yearly Salary
Monthly Pay
Reason for Leaving
Describe any other job training or education you have completed:*
(If none, enter none or n/a)

Notification Preference
As a courtesy, we would like to notify you of the initial status of your application. This is optional and is just our way of keeping you informed of the process. Once the campus reviews your application, they will be contacting you. If you would like us to let you know of the initial status of processing, please indicate your preference.
Follow-Up Contact Preference*

No Initial ContactPhoneEmail
Should be Empty:

General Information