Admissions Requests


SERVICES • ADMISSIONS POLICY • WHAT IT COSTS

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
The Pastor at your church told you
Other


Address:

City:

State:

Zip Code:

Telephone Numbers:
(Home):


(Work)


(Cell)

Your Relationship to the Children:

Children for whom admission is requested:

Name: (First Child)

D.O.B.

Sex:
Male Female

Name: (Second Child)

D.O.B.

Sex:
Male Female

Name: (Third Child)

D.O.B.

Sex:
Male Female

Name: (Fourth Child)

D.O.B.

Sex:
Male Female

Name: (Fifth Child)

D.O.B.

Sex:
Male Female

Who has legal custody of the children?

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

 

Main Image
Palmer Home for Children is recognized as a charitable, not-for-profit corporation under Mississippi law. We are also recognized as a 501(c)(3) public charity under federal law.

Bottom Right Image