RSR STUDENT APPLICATION FORM

PARENT/GUARDIAN INFORMATION
Parent/guardian 1
Parent/Guardian1*

First NameLast Name
Relation*
Phone Number*
Email Address 1*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/guardian 2
All legal guardians must be listed. In cases of joint custody, legal documents must be submitted by fax or email. Email info@RockSolidRefuge.com or fax 306-297-3063
Parent/Guardian 2

First NameLast Name
Relation
Phone Number
E-mail address 2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Who has legal guardianship?(List all)*

FAMILY HISTORY, LIFESTYLE, CORE ISSUES
Describe your family history concerning adoption, divorce, separation etc. (min. one-page writeup)*
Describe your son's lifestyle concerning drugs, alcohol, or behaviour issues (min. one-page writeup)*
Describe what you believe are the core issues in your son's dysfunctional behaviour and when they came about (min. half-page writeup)**

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	Yes	No
Has a psychiatric condition
Uses medication
Has a history of violence
Has been in juvenile detention
Has court cases pending
Has outstanding warrants for arrest
Has restraining order against him

	Yes	No
Are his explanations for irresponsible behaviour or decreasing performance implausible? Is he frequently dishonest?
Has his personality changed? (mood swings, hostility, giddiness, or irritability)
Has anyone expressed concern about his alcohol/drug use? Have you found signs of drug use such as bottles, drugs, or paraphernalia?
Is he less responsible with chores; schoolwork; being on time?
Have his grades dropped? Has his interest in school activities decreased?
Is he increasingly secretive about his whereabouts? Has he become withdrawn and uncommunicative?
Does he spend a lot of time alone?
Have you noticed alcohol or pills missing from your home?
Does he show a lack of motivation or an apathetic attitude?
Are you missing money, credit cards, or valuables?
Does he seem to have difficulty remembering things?
Is there a change in his personal hygiene, dress habits, or sleeping and eating habits?
Have you noticed physical indicators of drug/alcohol abuse? (red eyes, dilated pupils, or slurred speech)
Have you observed irrational or explosive behaviour?
Are there signs of medical or emotional problems such as depression, anxiety, suicidal ideation, ulcers, or gastritis?
Is there evidence he is involved in the occult?
Has his peer group changed to include friends who are involved in drinking, drug use, and partying?