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Student Application
Student Basic Information
Full Name
Phone Number
Email Address
Grade Level
*
Student Social Security Number
Address
Home Phone
Student Birthday
Height
Weight
Eye Color
Nickname
Identifying marks or characteristics
Parent Information
Father's Information
Father's Name
Social Security Number
Address
Phone
Email
Marital Status
Date of Birth
Mother's Information
Mother's Name
Social Security Number
Address
Phone
Email
Date of Birth
Marital Status
Grandparent Information
Grandparent's Name
Email Address
Phone Number
Address
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Church Information
Pastor's Name
Religion
Legal Custody Information
Who has legal custody?
Do you receive financial subsidy for your daughter?
*
A
Yes
B
No
If legal custodian is not parent, fill out the following:
Legal Custodian's Name
Legal Custodian's Occupation
Legal Custodian's Address
Legal Custodian's Phone
Relationship to child
Legal Custodian's Email
Sibling Information
*
Social History
Briefly describe the reasons why placement is being sought:
Describe your Child's relationship with you and other family members
Describe the problems your child is experiencing and the circumstances contributing to them:
Describe your child's behavior, including both acceptable and unacceptable actions:
Describe any placements outside of the home, including the reason for placement, dates, and results:
Give a brief family history covering any major events in your child's life from birth to the present:
Describe your child's social life and activities:
Describe the strengths in your family that you consider have helped your child in the past and will help in the future.
*
What do you expect to happen to your child and to your family as a result of your relationship with Victory Village?
*
Signature
*
Sign here
Date
*
Submit
