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Home
About Us
COVID-19 Response
Our Leadership
Accountability & Licensing
Vision – Mission – Values
Success Stories
2019 Impact Report
Admission Information
Frequently Asked Questions
Our Privacy Policy
How We Help
COVID-19 Response
Children in Crisis
Teen Boys
18+ Transitional Housing
Relative caregivers
Success Stories
Our Campus School
Admission Information
Events
SuperHeroes Run for Hope
Country Connection Concert
Bethel Golf Classic
Open House – Rental Homes
Giving Tuesday 2020
Blogs
Serve
Volunteer
Feed Kids at Bethel
Host a Food and Supply Drive
Careers
Contact
Contact Us
Admission Information
Quick Help Form
Get News from Bethel!
Careers
Bethel Alumni Portal
Give
Text To Give
Be a Hero for Hope
Feed Kids at Bethel
Giving Tuesday 2020
Give Online
Year-end Giving
Host a Food and Supply Drive
Bethel Thrift Store
Bethel Bible Village
3001 Hamill Road Hixson, TN 37343
(423) 842-5757
info@bethelbiblevillage.org
Give Now
Home
Bethel Admission Application
Bethel Admission 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
Your name
*
Name of legal guardian submitting this application
Your Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Information About This Child
Name of Child
*
First
Middle
Last
Age of child
*
Child's birthday
*
Date Format: MM slash DD slash YYYY
Child's gender
*
Male
Female
Child's Race or Ethnicity:
Does the child live with you now?
*
Yes
No
If this child does not live with you, who does he or she live with?
*
What date did the child begin living with this person?
*
Date Format: MM slash DD slash YYYY
How many people live in the home , including this child?
*
Child's current address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
A Quick 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 "Not a Concern."
1. Not getting good grades in school
*
In the past 6 months
More than 6 months ago
Not a concern
2. Getting in-school or out-of-school suspensions
*
In the past 6 months
More than 6 months ago
Not a concern
3. Getting into fights
*
In the past 6 months
More than 6 months ago
Not a concern
4. Feeling anxious/worried/stressed out
*
In the past 6 months
More than 6 months ago
Not a concern
5. Feeling lonely
*
In the past 6 months
More than 6 months ago
Not a concern
6. Feeling down or depressed
*
In the past 6 months
More than 6 months ago
Not a concern
7. Self-harm such as cutting or other self harm
*
In the past 6 months
More than 6 months ago
Not a concern
8. Wishing he/she was dead
*
In the past 6 months
More than 6 months ago
Not a concern
9. Holding in his/her anger (not expressing or discussing it)
*
In the past 6 months
More than 6 months ago
Not a concern
10. Exploding with anger
*
In the past 6 months
More than 6 months ago
Not a concern
11. Damaging belongings or things that belong to others
*
In the past 6 months
More than 6 months ago
Not a concern
12. Stealing
*
In the past 6 months
More than 6 months ago
Not a concern
13. Lying
*
In the past 6 months
More than 6 months ago
Not a concern
14. Using alcohol
*
In the past 6 months
More than 6 months ago
Not a concern
15. Using tobacco
*
In the past 6 months
More than 6 months ago
Not a concern
16. Using drugs illegally or dealing drugs
*
In the past 6 months
More than 6 months ago
Not a concern
17. Difficulty coping with a family member’s drinking and/or drug use
*
In the past 6 months
More than 6 months ago
Not a concern
18. Difficulty coping with feelings about being adopted
*
In the past 6 months
More than 6 months ago
Not a concern
19. Difficulty coping with past physical abuse, emotional, or sexual abuse
*
In the past 6 months
More than 6 months ago
Not a concern
20. Difficulty coping with divorce or separation of his or her parents/guardians
*
In the past 6 months
More than 6 months ago
Not a concern
21. Difficulty coping with the death of someone close to him/her
*
In the past 6 months
More than 6 months ago
Not a concern
22. Difficulty getting along with family members
*
In the past 6 months
More than 6 months ago
Not a concern
23. Difficulty getting along with people outside of the family
*
In the past 6 months
More than 6 months ago
Not a concern
24. Difficulty getting along with authority figures
*
In the past 6 months
More than 6 months ago
Not a concern
25. Having friends who are a bad influence
*
In the past 6 months
More than 6 months ago
Not a concern
26. Setting fires
*
In the past 6 months
More than 6 months ago
Not a concern
27. Hurting animals
*
In the past 6 months
More than 6 months ago
Not a concern
28. Not doing household chores
*
In the past 6 months
More than 6 months ago
Not a concern
29. Poor hygiene
*
In the past 6 months
More than 6 months ago
Not a concern
30. Weight problems
*
In the past 6 months
More than 6 months ago
Not a concern
31. Being arrested or detained by the police
*
In the past 6 months
More than 6 months ago
Not a concern
32. Gang involvement
*
In the past 6 months
More than 6 months ago
Not a concern
33. Is or has been sexually active
*
In the past 6 months
More than 6 months ago
Not a concern
34. Pornography (internet or other)
*
In the past 6 months
More than 6 months ago
Not a concern
35. Inappropriate sexual behavior toward others
*
In the past 6 months
More than 6 months ago
Not a concern
36. Running away
*
In the past 6 months
More than 6 months ago
Not a concern
37. Loss of friend due to move or death
*
In the past 6 months
More than 6 months ago
Not a concern
38. Dealing with a break-up
*
In the past 6 months
More than 6 months ago
Not a concern
39. Bedwetting
*
In the past 6 months
More than 6 months ago
Not a concern
40. Loss of a pet
*
In the past 6 months
More than 6 months ago
Not a concern
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?
*
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?
*
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.
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:
*
Me
Another person
Deceased
If deceased, the person's name
*
How long ago? What was the cause of death?
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:
*
Me
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.
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?
*
Yes
No
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?
Yes
No
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?
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.
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
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
Date Format: 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.
Date Format: MM slash DD slash YYYY
Release of Additional 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?
*
Yes
No
List
Name
Type (therapist, psychologist, etc.)
City/State
Phone
Agency/organization
Does the Department of Children's Services have records for your child?
*
Yes
No
What location?
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Name of case worker (if known)
First
Last
Phone number
Has the child had court involvement?
*
Yes
No
Does the child have a probation officer?
Yes
No
What location?
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Probation officer's name (if known)
First
Last
Phone number
Is there anyone else who has records for this child that will be helpful for us to see?
*
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.
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.
First
Last
Date of Signature
This authorization is valid for one year from the date signed below.
Date Format: MM slash DD slash YYYY
Child's Medical Information
Does the child have any allergies?
*
Yes
No
What kind of allergies?
*
Food
Bee stings
Seasonal
Animals
Other
If other, what kind?
Has the child ever had surgery?
*
Yes
No
Please tell us what kind of surgery and when the child had surgery?
*
Type of Surgery
Date
Has the child ever been hospitalized for medical reasons?
*
Yes
No
Please tell us why and when the child was hospitalized
*
If you need to add more lines, click on the + at right. Add as many additional lines as you need.
Reason hospitalized
Date
Has the child had a mental health diagnosis? (current or past)
*
Yes
No
What was the diagnosis?
Current
Past
Has the child had any out-of-home programs or mental health hospitalizations, whether past or current?
*
Yes
No
If yes, please list any out-of-home programs or mental health hospitalizations for this child, whether past or current.
*
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
Type of service
Dates of stays
Does the child currently take any medications?
*
Yes
No
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?
Yes
No
Past Medications
To add additional lines, please click the + sign at the right side.
Medication
Reason for medication
How long?
Does the child have any other significant medical issues? If so, please list them here.
Referrals
How did you find out about Bethel?
*
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?
*
Name of person who referred you (if known)
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
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
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Your Name
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Last
How can Bethel help you?
*
What is the best way to get in touch with you?
*
Phone
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Phone Number
*
Do we have your permission to leave you a voice mail at this number?
*
Yes
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Your Email Address
*
Enter Email
Confirm Email
Where do you live?
*
City
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How did you find Bethel?
*
A counselor or social worker referred me
A court referral
A friend or relative
Other
If other, how?
*
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