APPLICATION FOR ADMISSION OF A CHILD INTO

THE THOMASVILLE BAPTIST ORPHANAGE

AT THOMASVILLE, N.C.

=======================================================

I. - CERTIFICATE OF RELATIVE OR FRIEND

Name of child? Havanna   Boy or girl?  Boy   Date of birth?  Oct. 24. 1900

Name of child? Brack  Boy or girl?   Boy   Date of birth?   Sept. 18.  1902

Place of birth?  Concord   Is the child of legitimate birth?  Yes   Truthful?  Yes

Honest? Yes  Addicted to any vicious habits?  No   How far advanced is the child in scholastic education?  (Blank)   Date of Parents Marriage.  June 1897

Father's name?  Adam HUNEYCUTT   Place of birth.  Stanly Co.  Date of birth?  1876

Moral character?  Good.  Died of what disease?  Tubuculosis.  When?  Oct. 1905

Where?  Stanly Co.    Mother's name?  Hattie H.     Maiden Name?  OVERCASH

Place of birth?  Rowan Co.  Date of birth?  Oct. 1878   Moral character?  Good

Died of what disease?  Not Dead.           When.  (Blank)     Where?     (Blank)

Is the child heir to any property?  Yes.   If so, about what is its value?  $45.00 an interest till they are of age.

Name of legal guardian. If any?     Lawyer PRICE, Albemarle

Was the father a member of any secret order?  If so, what?    No.

If either  parent is living, but unable to support the child, state why.  It it is a case of mental or physical inability send a certificate as to condition and cause by some respectable Physician.   (Blank)

I bear witness to the fact that the answers given above are true and accurate to the best of my knowledge and belief, and that I commit the children to the Orphanage with the promise that I will not interfere with their management in any way.   I sustain to this child the relation of.    Mother.

(Signed) Hattie HONEYCUTT     Address:  Concord, N.C.   Date.  8/6/1910

=============================================================

II. - CERTIFICATE OF PASTOR.

( OR OF OTHER CHURCH OFFICER IN CASE THE CHURCH HAS NO PASTOR)

Was the father of above named child known to you?   No.

What was his relationship to the church?  Member.  

Was the mother known to you?   Yes.  

What was her relation to the church?     Member

What was is the child's church relationship?  Mem.

Do you believe the child to be destitute and worth of aid?  Yes.

Do you regard the child as reasonably bright and capable of receiving an education? Yes.

==============================================================

III. - CERTIFICATE OF PHYSICIAN.

Has the above named child diseased scalp?   No.   Scrotulous sotea?  No.

Sore eyes?   No          Any skin disease?  If so, what?   No.    Defective hearing?   No

Defective vision?   No         Defective speech?           No.   Epilepsey?   No

Syphillis?   No.                       Idiocy?   No.                   Feeble mindedness?   No.

Weak heart?  No.                   Kidney trouble?   No.     Enlargement of liver?   No

Tuberculosis?   No                  Catarrh?   No          Has the child had measles?  Yes

Mumps?   Yes                      Smallpox?  No                        Scarlet Fever?  No

Whooping cough.  Yes              Diphtheria.   No                    

Has the child  been successfully vaccinated?  No         Any deformity?   No

Evidence of evil results from any disease?  No

(Signed) D. ?????? CALDWELL M.D.     Address:   Concord, N.C.

Note:  To the side of this document it is written:

Accepted Aug. 31.10