Transcription of SHILOH HOME, INC
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SHILOH HOME, INC
Admission Application Confidential to SHILOH House Date: Start Date: Anticipated Length of Placement: Paying Agent Name: DOB: Place of Birth: Referring County Program Medicaid #: Social Security #: Reason for placement: Physical Description of child: Sex: Weight: Height: Hair Color: Eye Color: Distinguishing Features: Additional Insurance/Group #: Religious Affiliation: Ethnicity: Hispanic-Latino Non-Hispanic or Latino Race: American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or other Pacific Islander Other Head of Household (Name): M F Household receives SSI/SSDI?
Shiloh House offers events where clients participate in such activities as holiday parties, picnics, public sporting events, Shiloh House community fundraising events and community entertainment activities. Community members/media may be in attendance of any/all of these events. My child has permission to participate in the
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