BALTIMORE COUNTY PUBLIC SCHOOLS
|Department of Academic Services | |Agency Placement-Qualifies for Out-of-County Tuition Recapture |
|Office of Pupil Personnel Services | | |
|PLEASE TYPE OR PRINT | | Yes No |Code | |
|COURT ORDER OR PLACEMENT LETTER MUST BE ATTACHED | |School ID | |
|PPW Name | | |Tuition Status | |
| | | | |
|Address | | |Signature of Pupil Personnel Worker Date |
|Zip | | | |
|Telephone | | | |
APPLICATION TO ENROLL STUDENT IN STATE-SUPERVISED CARE
|1. |Name of Child | |Last School, City, State | |
| |
|2. |D.O.B. | |Student ID# | | |Grade for Year of Application | |
| |
|3. |Name of Birth Mother | |Phone | |
| |
| |Address | |City, County | |State | |Zip | |
| |
|4. |Name of Birth Father | |Phone | |
| |
| |Address | |City, County | |State | |Zip | |
| |
|5. |Have parental rights been terminated? | Yes No |
| |
| |
|6. |Court awarded guardianship/custody to: Mother Father Other (Not Foster Parent) |
| | |
| |Name Address City/County State |
| |Zip |
| |
|7. |If custody has not been awarded, with whom does the child live when not in a foster care home or residential facility? |
| |Mother Father Other ___________________________________________________________________________ |
| |
|8. |Is this child receiving special education services? Yes No LRE Code _______________ 504 Yes No |
| |
|9. |Does the student have a parent surrogate? Yes No |
| |
| |Name of Surrogate | |Phone (Home) | |(Work) | |
| |
| |Address | |City, County | |State | |Zip | |
| |
| |Baltimore County Home School | |
| | | |
| |Is the child staying in an emergency, temporary, or transitional shelter? If yes, child must be immediately enrolled pursuant to | Yes No |
| |PS 512. | |
| |
|10. |Agency with Order of Care | | |
| |
| |Address of Agency | |City/County | |State | |Zip | |
| |
| |Social/DJS/Worker (Print) | |D&T/ID# | |Supervisor (Print) | |
| |
| |Worker’s Phone | |Fax | |Supervisor’s Phone | |
| |
| |
|11. |Is this application for the purpose of transportation only? Yes No |
| |
|12. |Has the student been institutionalized, hospitalized, or in DJS placement since the last school placement? |
| |
| |Where | | |Date | |
| |
| |(Circle One) Foster Family/Kinship Care/Group Home | |Contractual Service Provider |
| |
| |Name | |Name |
| |Address | |Address |
| |Zip Code | |Zip Code |
| |Telephone (Home) | |Name of Case Worker |
| | (Work) | |Telephone | |Fax | |
| |Baltimore Co. Home School | |Residential Yes No |
| |
| |
| |Signature of Social/DJS Worker | |Date |
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