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Bethel Admissions Application

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Please Note

You must be the child's legal guardian to submit this application. The child must be younger than age 18. Before you submit this application, please make sure you have read and understand Bethel's admission process, Christian beliefs, the situations we can serve, and our Family Involvement policy. These are available at www.bbv.org/admission.

Your Information

Name of legal guardian submitting this application
Your Address(Required)
What is your relationship to this child?(Required)
In addition to legal guardian
I prefer that Bethel contact me:(Required)
Do we have your permission to leave a voicemail?(Required)
Your marital status(Required)
If married, please provide a little of information your spouse.
If you do not know the answers to any of these questions, type "don't know" in the box.
Name
Relationship to the child
Address (If different from you)
Age
Phone
Level of involvement with child
General health
Where employed
Shift/Work hours
 
Church families are often good sources of support during a crisis.

Information About This Child

Name of Child(Required)
MM slash DD slash YYYY
Child's gender(Required)
Does the child live with you now?(Required)
MM slash DD slash YYYY
Child's current address(Required)

Behavioral Checklist

Please let us know which of the following behaviors have you concerned for this child, and indicate whether it is a recent problem, one that occurred in the past six months, or longer than six months ago. For any behaviors that do not apply to this child, check "Has Not Occurred."
1. Getting low grades in school(Required)
2. Getting in-school or out-of-school suspensions(Required)
3. Getting into fights(Required)
4. Feeling anxious/worried/stressed out(Required)
5. Feeling down or depressed(Required)
6. Self-harm such as cutting or other self-harm(Required)
7. Wishing he/she was dead(Required)
8. Exploding with anger(Required)
9. Damaging/breaking things that belong to him/her or others(Required)
10. Stealing(Required)
11. Lying(Required)
12. Using alcohol(Required)
13. Using tobacco(Required)
14. Using drugs illegally or dealing drugs(Required)
15. Has he/she experienced emotional, physical, or sexual abuse, or neglect?(Required)
16. Difficulty coping with a family member’s drinking and/or drug use(Required)
17. Difficulty coping with feelings about being adopted(Required)
18. Difficulty coping with divorce or separation of his or her parents/guardians(Required)
19. Difficulty coping with the death of someone close to him/her(Required)
20. Difficulty getting along with family members(Required)
21. Difficulty getting along with people outside of the family(Required)
22. Difficulty getting along with authority figures(Required)
23. Having friends who are a bad influence(Required)
24. Setting fires(Required)
25. Hurting animals(Required)
26. Not doing household chores(Required)
27. Poor hygiene(Required)
28. Weight problems(Required)
29. Being arrested or detained by the police(Required)
30. Gang involvement(Required)
31. Sexually active(Required)
32. Pornography (internet or other)(Required)
33. Inappropriate sexual behavior toward others(Required)
34. Running away(Required)
35. Difficulty dealing with a break-up(Required)
36. Bedwetting(Required)
37. Loss of a pet(Required)

Family Relationships and History

If there is information in this section that you do not have, please type "don't know" in the field.
Have any of these situations existed in the child's family?(Required)
Check all that apply, even if they happened in the past.
Do you share legal custody for this child with another person?(Required)
I share legal custody of the child with:
If yes, please provide a little of information about this person:
If you do not know the answers to any of these questions, type "don't know" in the box.
Name
Relationship to you
Relationship to the child
Location
Marital Status
Age
Phone
Level of involvement with child
General health
Where employed
Shift/Work hours
 
The child's biological mother is:(Required)
Tell us what you know about the child's biological mother.
Name
Relationship to you
City / State
Marital Status
Age
Phone
How involved with child
General health
Where employed
Shift/Work hours
Church?
 
The child's biological father is:(Required)
Tell us what you know about the child's biological father.
If you do not know the answers to any of these questions, type "don't know" in the box.
Name
Relationship to you
Relationship to the child
Location
Marital Status
Age
Phone
How involved with child
General health
Where employed
Shift/Work hours
Church?
 
Does the child have any siblings?(Required)
Siblings
To add more siblings, click on the + sign at right and add as many lines as you need.
Sibling's Name
Sibling's Age
Lives in home with child? (Yes, no, or sometimes)
 
Are there are other children in addition to siblings (not listed in this document so far) who live in the house with the child?
If yes, please list their names and ages.
Name
Age
 
Are there are other adults (not listed in this document so far) who live in the house with the child?
Tell us a little about this person.
If there is more than one adult and you have not listed them in a previous question? You can click on the + sign at right to add as many lines as you need for adults living in the home with the child.
Name
Relationship to you
Relationship to the child
Marital Status
Age
Phone
How involved with child
General health
Where employed
Shift/Work hours
Church?
 
Please list any other people who are significantly involved with the child.
Include any family or non-family members who have NOT been listed above, who have a close relationship with the child, such as a pastor, youth pastor, relative or family friend.
Name
Age
Relationship
 

Other Agencies Involved/Release of Records

This information helps Bethel gather the information we need to better understand the specific needs of the child.
Has the child seen a counselor or other mental health professional?(Required)
List
Name
Type (therapist, psychologist, etc.)
City/State
Phone
Agency/organization
Dates of treatment
 
Does the Department of Children's Services have records for your child?(Required)
What location?
Name of case worker (if known)
Has the child had court involvement?(Required)
Does the child have a probation officer?
What location?
Probation officer's name (if known)
Is there anyone else who has records for this child that will be helpful for us to see?(Required)
If so, please list their contact information here.
If you need more lines, click on the + sign to add as many as you need.
Name
Relationship or Title
Phone Number
 
This is my electronic signature. With this signature I authorize the release of my child's records to and from Bethel Bible Village and the Professionals/Agencies above.
I understand the information will Bethel to obtain/release medical, psychological, legal or other information for the child listed in this Release of Additional records. I understand any information obtained/released will be used to determine present and/or future needs for the well-being of this child. All information will be placed in the child’s private file and will only be available to appropriate personnel and/or agencies. This consent for release is given freely, voluntarily, and without coercion for one year from the date of signature.
This authorization is valid for one year from the date signed below.
MM slash DD slash YYYY

Child's Medical Information

Does the child have any allergies?(Required)
What kind of allergies?(Required)
Has the child ever had surgery?(Required)
Please tell us what kind of surgery and when the child had surgery?(Required)
Type of Surgery
Date
 
Has the child ever been hospitalized for medical reasons?(Required)
Please tell us why and when the child was hospitalized(Required)
If you need to add more lines, click on the + at right. Add as many additional lines as you need.
Reason hospitalized
Date
 
Does the child have a mental health diagnosis?(Required)
Has the child had any out-of-home programs or mental health hospitalizations, whether past or current?(Required)
If yes, please list any out-of-home programs or mental health hospitalizations for this child, whether past or current.(Required)
Some examples: Valley Hospital, Scholze Center, Residential Treatment Centers, Foster or Group Homes) If you need to add more lines, click on the + at right. Add as many additional lines as you need.
Agency
Dates of stays
Reason for Stay
 
Does the child currently take any medications?(Required)
Current Medications
If you need to add more lines, click on the + at right. Add as many additional lines as you need.
Medication
Reason for medication
How long?
 
Did this child take any medications in the past?
Past Medications
To add additional lines, please click the + sign at the right side.
Medication
Reason for medication
For how long?
 

Referrals

How did you find out about Bethel?(Required)

Statement of Truth

I hereby request that Bethel Bible Village consider providing services to:(Required)
Child's full name
Terms and Conditions(Required)
By checking this box I verify that I have read and understand Bethel's information on the admission process, Christian beliefs, financial responsibility, the situations Bethel can serve, and Bethel's family involvement policies. These are available online at www.bbv.org/admission or you can request the information in an email from David Shinn, DShinn@bethelbiblevillage.org
This is my electronic signature. With this signature I authorize the release of all records to and from Bethel Bible Village that are listed above.(Required)
All information provided here is accurate to the best of my knowledge. I understand that any deliberately false information is grounds for denial. This application is valid for six months from date of submission.
MM slash DD slash YYYY

School Records

This helps Bethel understand the child's educational needs.
What school is the child attending now?(Required)
School Name
Grade
City
State
Any Special Ed services?
 
Please list any other schools the child has attended in the last two years.
Need more lines? Click on the + sign to add as many as you need.
School Name
Grade
City
State
Any Special Ed services?
 

School Records Release: I hereby authorize the release of all educational records to and from Bethel Bible Village and the schools listed above for the child listed below.

Child's Full Name(Required)
MM slash DD slash YYYY
This is my electronic signature as this child's legal guardian. With this signature I authorize the release of all educational records to and from Bethel Bible Village and the schools listed above.(Required)
This information includes special education records, if applicable. I understand the information released will be used to determine present and/or future needs for the well-being of this child. All information will be placed in the child’s private file and will only be available to appropriate personnel and/or agencies. This consent for release is given freely, voluntarily, and without coercion and is valid for one year from the date signed.
This authorization is valid for one year from the date signed below.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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BETHEL BIBLE VILLAGE
3001 HAMILL ROAD HIXSON, TN 37343
(423) 842-5757
info@bethelbiblevillage.org

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Helping children find freedom from the past and hope for the future | © Bethel Bible Village 2021 All rights reserved.