NEW BETHANY BAPTIST CHURCH NEW BETHANY HOMES fOR GIRLS AND BOYS

ARCADIA,
MACK \~.

Rt 2 Box 2222 LOUISIANA 71001

FORn

PASTOR

& DIRECTOR

DEAR PARENTS,

We appreciate your desire to place your child with the Boy's Home ministry. \~e have listed below some requirements that have proven to be best for those who corne for help. If for some reason you cannot meet our requirements please discuss this in full with the office. Please prayerfully conside~ the following:
REQUI RE~'[ENTS I.

MEDICAL

A.
B.

C.
D_

E. F. G.

Complete Doctors' physical Herpes II (IGM) Blood tes t" .~ ., HIV Or HTLV TIl (Ains Blood test) R?P Bloo~ t~st for v8neral rliseases Eye examination to insure proper progress in school. A statsment from the Doctor is required as well as glasses purchased if needed. All dental work mus+' be completed. Cavities must be filled with a permunent filling and not temporary fillings which cause problems. A statement from the dentist is required. . . A cory of the computer report from the lab is r~ewuired'showing the test results and the interpretation of those results. These must be mailed into the office. All tests must be in the negative range for acceptance Your child will not be accepted until we have the physical and the copies of all lab reports. You will be called so that a final acceptance m~y be m3de as well as arranging a time and date of arrival. - see enclosed copy of Power of Attorney and Affidavit address

II.

LEGAL PROCEDURES

III.A copy of school report cara, withdrawal slip, as well as complete of school so the records may be requested IV. Recent picture, V. A.C.E. Uniforms copy of Birth Certificate, are required. health records.

We order them upon arrival.

VI. On~ pho~p. call p~r month

be~inning three weeks after arrival. No calls permitted on Sunday. Calls may be from parents or guardians only and may last five to ten minutes. to send two, one page letters per week to only. The church Pastor may be added. All will be from parents, grandparents and Pastors to be brought or sent from home.

VII.Each boy will be allowed parents and grandparents correspondence from home ONLY. VI I Hlo p i c t ur e's are allowed

IX. FINANCES
A. An allowance of $20 or $25 is required monthly, PAYABLE TO THE CHILD. Be sure to enclose the monthly allowance in a personal letter to the child. All money will be kept in the office and will be used as needed for his supplies. $125.00 for entrance fees, Registration and ACE curriculum for 12 months (non refundable). All medical, dental, and other personal bills will be mailed to you for payment.

B. C.

X.

ITEMS TO BRING (HARK ALL PERSONAL IN BOLD LETTERS) STURDY FOOT LOCK~R 3 Wash Cloths

ITEMS WITH A PER.~NE'lT MARKER

3 Towels,

I Set of Twin Sheets,

I pillow case

1 Pair Tennis Shcs, 1 Pair Black Dress Shoes for School, 1 Pair Boots or Dress Shoes for Church, 1 Pair Rubber or Work Boots. 4 Play or Work Shi~ts,

.~

nothing on the front of them

"..

4 Pair of Jeans - No STONE WASH, ACID WASHED OR TYDYED

7 ~biT of s~cks, 2 Fair uI Dress Socks

;EANS

SUIT: NAVY BLUE SUIT COAT, 1 PAIR NAVY, GRAY AND TAN r .NTS. 3 ~ress Shirts and 3 Ties to match 2 Belts I 1 Pair Work 6 1 1 1 1 Changes Pal~ of Pair of Robe Pair of Gloves

of Underclothing Swinning Trunks Pajamas House Shoes 1611 Edition with good bindin~.(KJV 1IBLE)

KING JAMES -Oriqional Fishing Polaroid

Rod - jackIe Box Camera

& Film
and Statior~ry o~ tablet of paper.

I Book of Stamps Envelopes

UPON ARR1.T.zu,

TO OUR CAMPUS

WE ASK THAT YOU DRESS ACCORDING TO OUR DRESS CODE. THIS WILL E"~LE YOU TO TOuR OUR C~WUS PROPERLY. WE ALSO ASK THAT YOU SPEND 2 or 3 DAYS WITH US. CHECKLIST FOR PAPERWORK DotTOR'S PHYSICAL SHEET AFFIDAVIT IN DIVORCE CASES HER~ES II BLOOD TEST REPORT SCHOOL TRANSCRIPTS OR ArDRESS AIDS LAB REPORT CURRENT PICTURE VENERAL DESEASE LAB REPORT BIRTH CERTIFICATE DEl;TAL STATEMr:1' - HEALTH P.ECORDS (IMMUNIZ.1'ION) PROOF OF EYE ::XAH HAVE YOU MET EVERY REQl'l REMENT? POWER OF ATTORNEY INSURANCE ON CH:LD

GENERAL

INFORMATION: YOU TO THE NEW BETHANY HOME MINISTRY?

WHO REFERRED

-----

PERSON TO CONTACT

IN CASE OF EMERGF,NCY IF J)ARENTS CA~NOT BE REACHED: RELATIONSHIP

mum

-----------------( ___________

---------------WE MAY CALL

PHONE NUMBER THEM COLLECT?

DO THEY UNDERSTAND

----AND GRANDPARENTS ONLY!!!!!!

CHILD MAY RECEIVE MAIL FROH PARENTS LIST GRANDPARENTS:

NAME

--~------------------.--------

ADDRESS

ADDRESS

---------------

NAME ADDRESS

FOR OUR INFOR~rnTION LIST NAMES AND AGF.S OF BROTHERS IN FAMILY:

NAME

AND

SISTERS

AGE

I THE PARENT

OF POOL AT THE NEW BETHANY LIABLE

DO GIVE THEM PERMISSION BAPTIST

TO SWIM

IN THE SWIMMING CHURCH

CHURCH AND DO NOT HOLD THE

(HOME MINISTRY)

FOR ACCIDENTS.

PARENT OR GUARDIANS

NAME

DATE

NEW BETHANY

BAPTIST

CHURCH BIRTROATE IN SCHOOL

MEDICAL

INFORMATION:

'

AGE --------------------ADDRESS GRADE

DATE _

NAME

-------

--------

STUDENT HISTORY:

(Xl CHECK THOSE STUDENT MEASLES CHICKEN

WHOOP I

HAS HAD. POLLEN ALLERGIES POX PNEUMONIA

LAZY EYE

DRUGS--FLASHBACKS DIABETES EPILEPSY RHEUMATIC ARTHRITIS SCARLET FEVER }~REQUENT COLDS HIGH BLOOD PRESSURE LOW BLOOD PRESSURE TUBERCULOSIS ANEMIA MENSTRUAL LEG CRAMPS DIZZINESS STRESS ACNE
MUMPS

NG COUGH DISEASE

FEVER

VENERAL

FREQUENT HEADACHBS , BOILS LICE WORTS BRAIN TUMOR CYSTS

ASTHMA

"._ KIDNEY OR BLADnER --' '".,' DISEASE JUANDICE HEART DISEASE LIVER DISEASE MIGRANE HEADACHES

RAPID WEIGHT LOSS RAPID WEIGHT GAIN

RAY FEVER CONVULSIONS

CRAMPS

FR~OUENT FAINTING 'PLEURISY

TONSILLITIS

SPELLS

..

EAR INFECTIONS TIRES EASILY NOSE BLEEDS

MALARIA

LOSS OF HAIR FREQUENT URINATION

SPEECH DIFFICULTIES BRONCHITIS HERPES

INFECTIOUS --- MONONUCLEOSIS

SINUS INFECTIONS THYROID DISEASE

1**

PERSONAL RECORD----------------------PLEASE
IS CHILO SHY OVERACTIVE_ BITES FINGERNAILS ___
SUCICTHUMB_ TEMPER TANTRUMS_

..

ANStiER ALL OF THE FOLLOWINGl WEARS GLASSES_

BED W'ETTER_

LIltES SCHooL_ EATS WELL_GRINDS

PLAYS ~,LL

TEETH IN SLEE~_
DISORDERS_

WITH OTHERS_GUM

EXCESSIVE

FEARS ___

ULCERATED MOUTH_

SCREAMS 'IN SLEEP_BRACES_ SENSATlVE TEETH_____ _

RETAINERS ___

WHEN IS REGULAR

BED TIME?_'

RISING TIME? __ -------------.".

LAwnRS

NAME

ATTOM...t:"! AT LAW N>DRESS

CITY,STATE AND lIP CODE

TELEPHONE NUMBER

POWER OF ATTORNEY
STATE OF KNOWN
COUNTY OF

--------~~------, County ~d
~s I

---------------------------------------------------------ALL MEN BY THESE PRESENTS THAT

,

OF parent of

,----------------------------------------State of : am the
,
ltute, and appoint Mack Ford and lawful Attorney for and in my name

and I~-ve this day made, constituted, and

.. ~

appointed-:~~-~~-~~:::-;~:::~~:-~::make the New Bethan~:Bapti5t Church, as

place: ~nd stead, to place my child_ in the care of Mack Ford and the New Bethany Baptist Church for twelve (12) months, or longer if deemed bY~ to administer corporal di.ci~ medical treatment. I also ~ Mack W. Ford; without visitation rights,
nd to make neces.ary decisions concerning

08e parties the right to read my child's to cooperate with the decisions of the

--------------------------------------------------------~-----------Parent (s) Name (5)

STATE OF

-----------~-------------

COtJN::Y OF

--------------------~--Thi. instrument wa. acknowledged before me on the

day

of

______________

19

by

----~-----------_ _

--------------------------------------~.
Notary Public, State of My Commission Expires
NAME

.. .

-----------------------------------

IN DIVORCE

CASES: AfFIDAVIT

STATE OF COUNTY OF

--------------------------II'

-'!'!'--

....

My name

is

--------------------------------

, I am

the

(mother. f~thel') of

----------------------------

I cn6~rstand

and

support the NO VISITATION Baptist Church to cooperate

RULE of Rev. Mack W. Ford, and the New Bethany for Girls and Boys Ministry. I also agree

in their Rome

with the decision!! of the administration.

(Father; or Mother's name)

Subscribed

and .worn to befo!eme

this seal.

th day of

, 19

, to

which witness

my han~ and official

(seal) Notary Public, State of __ _

.. . .

My Commission

Expirel

.. ----,--

.......