Online Admissions Request

If you know of children you believe could benefit by being placed at Palmer Home for Children, please review our admissions policy and complete the form below.

You will be contacted by our Children's Services staff after they review your request. You will be contacted regardless of whether we are able to accept or not accept your child/children for placement. This form is just the beginning of the application process, and additional applications and forms will need to be completed before any child is admitted to Palmer Home.

Initial Admissions Request

"Items colored red are required entries"

Person Making Application: Name:
E-Mail: Please tell us how you found our website: Search Engine Palmer Home Literature Visit to Palmer Home Palmer Home speaker at your church A friend told you about our website The Pastor at your church told you Other (please explain in comments)
Address:
City:	State:	Zip Code:

Telephone Numbers:
(Home):	(Work)	(Cell)
Your Relationship to the Children:

Children for whom admission is requested:

Name: D.O.B. Sex:Male Female

Name: D.O.B. Sex: MaleFemale

Name: D.O.B. Sex:Male Female

Name: D.O.B. Sex:Male Female

Name: D.O.B. Sex:Male Female

Who has legal custody of the Children:

Please give a brief description of the problem which necessitates out placement:

Palmer Home for Children - P.O. Box 746, Columbus, MS 39703 - Phone:(662)328.5704

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