Bethel Admission Application

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
Your name*
Name of legal guardian submitting this application
Your Address*
Street Address Address Line 2 City State ZIP Code
Which county?
What is the overall reason for seeking help from Bethel? Please include your main concerns and goals.*
What is your relationship to this child?*
In addition to legal guardian
- Biological Parent
- Grandparent
- Step-parent
- Aunt or uncle
- Adoptive Parent
- Other
If other, what is the relationship?*
How involved are you in this child's life?*
Your primary phone number*
Alternate phone number
Alternate phone number
Your email address
I prefer that Bethel contact me:*
- Phone
- Email
Do we have your permission to leave a voicemail?*
- Yes
- No
Your age*
Describe your general health. Do health problems make it more difficult for you to care for this child?*
Where do you work?
What hours or shift do you work?
Your marital status*
- 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.
Name Relationship to the child Address (If different from you) Age Phone Level of involvement with child General health Where employed Shift/Work hours
How 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.

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School Records
This helps Bethel understand the child's educational needs.
What school is the child attending now?*
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*
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.*
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*
This authorization is valid for one year from the date signed below.
MM slash DD slash YYYY

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Statement of Truth
I hereby request that Bethel Bible Village consider providing services to:*
Child's full name
First Middle Last
Terms and Conditions*
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 educational records to and from Bethel Bible Village and the schools listed above.*
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
Name
This field is for validation purposes and should be left unchanged.

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Name	Type (therapist, psychologist, etc.)	City/State	Phone	Agency/organization

Bethel Admission Application

Please Note

Your Information

Information About This Child

A Quick Behavioral Checklist

Family Relationships and History

School Records

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.

Release of Additional Records

Child's Medical Information

Referrals

Statement of Truth

Links

About

Services

Name	Relationship to the child	Address (If different from you)	Age	Phone	Level of involvement with child	General health	Where employed	Shift/Work hours

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

Name	Relationship to you	City / State	Marital Status	Age	Phone	How involved with child	General health	Where employed	Shift/Work hours	Church?

Sibling's Name	Sibling's Age	Lives in home with child? (Yes, no, or sometimes)

School Name	Grade	City	State	Any Special Ed services?

School Name	Grade	City	State	Any Special Ed services?

Type of Surgery	Date

Reason hospitalized	Date