What is the name of the child you are choosing to nominate?
Your answer
How do you know the child you are nominating? *
Your answer
What services is this child currently receiving (therapy, childcare, etc.)?
Your answer
How long ago did this child experience/witness domestic violence or another form of abuse?
Your answer
Is the child currently in a stable home environment (i.e. was not recently put into foster care, no longer lives with the abusive party, etc.)? If so, please describe.
Your answer
Has this child had the opportunity to process their trauma with a mental health professional? If so, please describe.
Your answer
How have you seen this child handle conflict or not getting their way? How does the child handle conflict?
Your answer
Does the child have any known behavioral issues? If yes, please describe.
Your answer
If this child has had behavioral difficulty in school recently, what has been the nature of that difficulty?
Your answer
What are some potential challenges that might arise if this camper attends Camp HOPE America-Arkansas?
Your answer
What do you believe that this child/family would gain from involvement in Camp HOPE America-Arkansas?
Your answer
Is there anything else that would be helpful for us to know in advance?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Women and Children First. Report Abuse