Bethel Admissions Application 1234567 Please NoteYou 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 InformationYour name(Required)Name of legal guardian submitting this application Your Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Which county? What is the overall reason for seeking help from Bethel? Please include your main concerns and goals.(Required)What is your relationship to this child?(Required)In addition to legal guardian Biological Parent Grandparent Step-parent Aunt or uncle Adoptive Parent Other If other, what is the relationship?(Required) How involved are you in this child's life?(Required)Your primary phone number(Required)Alternate phone numberAlternate phone numberYour email address I prefer that Bethel contact me:(Required) Phone Email Do we have your permission to leave a voicemail?(Required) Yes No Your age(Required) Describe your general health. Do health problems make it more difficult for you to care for this child?(Required)Where do you work? What hours or shift do you work? Your marital status(Required) Single Married Separated Divorced Widowed 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.NameRelationship to the childAddress (If different from you)AgePhoneLevel of involvement with childGeneral healthWhere employedShift/Work hours Add RemoveHow long have you been married? How long have you been separated? How long have you been widowed? How long have you been divorced? Do you attend/belong to a church? If so, which one?Church families are often good sources of support during a crisis. Information About This ChildName of Child(Required) First Middle Last Age of child(Required)Child's birthday(Required) MM slash DD slash YYYY Child's gender(Required) Male Female Child's Race or Ethnicity: Does the child live with you now?(Required) Yes No If this child does not live with you, who does he or she live with?(Required) What date did the child begin living with this person?(Required) MM slash DD slash YYYY How many people live in the home , including this child?(Required) Child's current address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Behavioral ChecklistPlease 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) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 2. Getting in-school or out-of-school suspensions(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 3. Getting into fights(Required) Occurred n the past 6 months Occurred more than 6 months ago Has Not Occurred 4. Feeling anxious/worried/stressed out(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 5. Feeling down or depressed(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 6. Self-harm such as cutting or other self-harm(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 7. Wishing he/she was dead(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 8. Exploding with anger(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 9. Damaging/breaking things that belong to him/her or others(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 10. Stealing(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 11. Lying(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 12. Using alcohol(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 13. Using tobacco(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 14. Using drugs illegally or dealing drugs(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 15. Has he/she experienced emotional, physical, or sexual abuse, or neglect?(Required) Yes No 16. Difficulty coping with a family member’s drinking and/or drug use(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 17. Difficulty coping with feelings about being adopted(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 18. Difficulty coping with divorce or separation of his or her parents/guardians(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 19. Difficulty coping with the death of someone close to him/her(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 20. Difficulty getting along with family members(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 21. Difficulty getting along with people outside of the family(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 22. Difficulty getting along with authority figures(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 23. Having friends who are a bad influence(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 24. Setting fires(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 25. Hurting animals(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 26. Not doing household chores(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 27. Poor hygiene(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 28. Weight problems(Required) Occurred the past 6 months Occurred more than 6 months ago Has Not Occurred 29. Being arrested or detained by the police(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 30. Gang involvement(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 31. Sexually active(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 32. Pornography (internet or other)(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 33. Inappropriate sexual behavior toward others(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 34. Running away(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 35. Difficulty dealing with a break-up(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 36. Bedwetting(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred 37. Loss of a pet(Required) Occurred in the past 6 months Occurred more than 6 months ago Has Not Occurred Family Relationships and HistoryIf 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. Frequent moves Family isolated / no support system Parent in jail or in prison Domestic violence Other family violence Alcohol abuse or other drug abuse Homelessness Serious physical illness Mental illness Financial stress Unemployent Suicide of Parent Other None of the above If other, please describe briefly.Do you share legal custody for this child with another person?(Required) Yes No I share legal custody of the child with: My spouse A former spouse with joint custody Other 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.NameRelationship to youRelationship to the childLocationMarital StatusAgePhoneLevel of involvement with childGeneral healthWhere employedShift/Work hours Add RemoveThe child's biological mother is:(Required) Me The same person I share joint custody with Another person Deceased If deceased, the person's name(Required) How long ago? What was the cause of death? Tell us what you know about the child's biological mother.NameRelationship to youCity / StateMarital StatusAgePhoneHow involved with childGeneral healthWhere employedShift/Work hoursChurch? Add RemoveThe child's biological father is:(Required) Me The same person I share joint custody with Another person Deceased If deceased, name of person How long ago? What was the cause of death? 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.NameRelationship to youRelationship to the childLocationMarital StatusAgePhoneHow involved with childGeneral healthWhere employedShift/Work hoursChurch? Add RemoveDoes the child have any siblings?(Required) Yes No SiblingsTo add more siblings, click on the + sign at right and add as many lines as you need.Sibling's NameSibling's AgeLives in home with child? (Yes, no, or sometimes) Add RemoveAre there are other children in addition to siblings (not listed in this document so far) who live in the house with the child? Yes No If yes, please list their names and ages.NameAge Add RemoveAre there are other adults (not listed in this document so far) who live in the house with the child? Yes No 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.NameRelationship to youRelationship to the childMarital StatusAgePhoneHow involved with childGeneral healthWhere employedShift/Work hoursChurch? Add RemovePlease 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.NameAgeRelationship Add Remove Other Agencies Involved/Release of RecordsThis 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) Yes No ListNameType (therapist, psychologist, etc.)City/StatePhoneAgency/organizationDates of treatment Add RemoveDoes the Department of Children's Services have records for your child?(Required) Yes No What location? City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Name of case worker (if known) First Last Phone numberHas the child had court involvement?(Required) Yes No Does the child have a probation officer? Yes No What location? City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Probation officer's name (if known) First Last Phone numberIs there anyone else who has records for this child that will be helpful for us to see?(Required) Yes No If so, please list their contact information here.If you need more lines, click on the + sign to add as many as you need.NameRelationship or TitlePhone Number Add RemoveThis 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. First Last Date of SignatureThis authorization is valid for one year from the date signed below. MM slash DD slash YYYY Child's Medical InformationDoes the child have any allergies?(Required) Yes No What kind of allergies?(Required) Food Bee stings Seasonal Animals Other If other, what kind? Has the child ever had surgery?(Required) Yes No Please tell us what kind of surgery and when the child had surgery?(Required)Type of SurgeryDate Add RemoveHas the child ever been hospitalized for medical reasons?(Required) Yes No 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 hospitalizedDate Add RemoveDoes the child have a mental health diagnosis?(Required) Yes No What is their diagnosis? Has the child had any out-of-home programs or mental health hospitalizations, whether past or current?(Required) Yes No 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.AgencyDates of staysReason for Stay Add RemoveDoes the child currently take any medications?(Required) Yes No Current MedicationsIf you need to add more lines, click on the + at right. Add as many additional lines as you need.MedicationReason for medicationHow long? Add RemoveDid this child take any medications in the past? Yes No Past MedicationsTo add additional lines, please click the + sign at the right side.MedicationReason for medicationFor how long? Add RemoveDoes the child have any other significant medical issues? If so, please list them here.ReferralsHow did you find out about Bethel?(Required) Counselor Juvenile Court/Probation Officer Social Worker or Social Service Agency Department of Children's Services/Child Protective Services School Friend or Family Member I searched online In the newspaper On TV On Facebook, Twitter or Instagram Other If other, who?(Required) Name of person who referred you (if known) Statement of TruthI hereby request that Bethel Bible Village consider providing services to:(Required)Child's full name First Middle Last 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 Yes 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. First Last Signature Date MM slash DD slash YYYY School RecordsThis helps Bethel understand the child's educational needs. What school is the child attending now?(Required)School NameGradeCityStateAny Special Ed services? Add RemovePlease 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 NameGradeCityStateAny Special Ed services? Add RemoveSchool 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) First Middle Last Child's Date of Birth 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. First Last Date of Signature(Required)This authorization is valid for one year from the date signed below. MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.