Child Intake Welcome to the Brittany's Hope Child Sponsorship Intake Form. Please complete all fields below. InformationSubmitter's Name First Last Submitter's Email Child's InformationChild First Name* Child Middle Name Child Last Name/Family Name* Child Nickname Gender*MaleFemaleChild DetailsChild Birthdate* MM slash DD slash YYYY Child Photos (Multiple Upload)* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 10 MB. Description of Child*LocationCenter*House of Love, Viet NamHa Tinh Village, Viet NamBen Tre Orphanage, Viet NamInjibara Children's Home, EthiopiaSt. Mary Magdalene Oasis of Peace, KenyaUkweli Home of Hope, KenyaLitein Community Program, KenyaCommunity, Viet NamIntake Date MM slash DD slash YYYY Arrival Date MM slash DD slash YYYY Enrollment Date MM slash DD slash YYYY Location*House of Love, Viet NamHa Tinh Village, Viet NamBen Tre Orphanage, Viet NamInjibara Children's Home, EthiopiaSt. Mary Magdalene Oasis of Peace, KenyaUkweli Home of Hope, KenyaLitein Community Program, KenyaSiblingsSiblings DescriptionPlease Describe the Family Situation & Family Background*Clothing Size Shoe Size Favorite Color*BlackBrownBlueGreenGreyOrangePinkPurpleRedWhiteYellowFavorite Toy*Action FiguresArts & CraftsBaby ToysBikesBooksDollsPuzzlesBoard GamesBuilding BlocksSports EquipmentToy CarsTeddy BearsFavorite Activity* Favorite Hobby* Favorite Animal* Personality Traits*Hold down Crtl to choose more than one.AffectionateAggressiveAnxiousCarelessCheerfulCries EasilyDaydreamsDependentEager to LearnEven TemperedFearfulFollowerFriendlyHappyHelpfulImmatureIndependentLeaderMoodyNervousOutgoingQuietRestlessSadSelf ConfidentSensitiveShares EasilyShyTalkativeUnusually FearlessVery ActiveBehavioral TraitsHold down Crtl to choose more than one.BitingBreaks ObjectsHead BangingHitting/KickingPinchingRefusal to CooperateScratchingStealingTantrumsThrows ThingsYellingHealthHeight (m)* Weight (kg)* Current Health*ExcellentGoodAverageFairPoorCriticalDiseaseMedical Condition (If Any) Reached Puberty? Yes No Treatment Treatment Center EducationSchool Type*PublicPrivateBoardingHome SchooledVocationalCollegeGraduatedNoneGrade/Year* Major/Training (If Any)ArtsAccountingAutomotiveBusinessCriminalDentalDivinityElectricalElectronicsEmbroideryEngineeringEnvironmentalFood Processing/ CulinaryHairdressingHotel & Restaurant ManagementHuman ServicesLanguageMedicalMusicSciencesTeachingTechnicalFavorite SubjectArtBiologyChemistryCivic EducationCREComputer StudiesEnglishGeographyHealthHistoryLanguageLiteratureMathMusicPhysical EducationPhysicsPsychologyReadingReligionScienceSocial StudiesSociologySpellingWritingSchool PerformanceExcellentGoodAverageFairPoorWork Experience FamilyParents Status*MarriedDivorcedSeparatedNever MarriedWidowedDeceasedUnknownChild's State At Entry to Program Neglected Abused Abuse Type Emotional Physical Sexual Mother's Name Mother's StatusDeceasedImpoverishedImprisonedMentally DisabledPhysically DisabledUnemployedUnfitUnknownMother's Location* Mother's Birth Year Mother's Occupation Mother's HealthExcellentGoodAverageFairPoorCriticalUnknownN/AMother's Medical Condition Mother's Deceased Date MM slash DD slash YYYY Father's Name Father's StatusDeceasedImpoverishedImprisonedMentally DisabledPhysically DisabledUnemployedUnfitUnknownFather's Location* Father's Birth Year Father's Occupation Father's HealthExcellentGoodAverageFairPoorCriticalUnknownN/AFather's Medical Condition Father's Deceased Date MM slash DD slash YYYY Last Known CaretakerSelfUnknown- AbandonedMotherFatherParentsSisterBrotherGrandmotherGrandfatherGrandparentsAuntUncleCousinStep-MotherStep-FatherGreat AuntGreat UncleNeighborInstitutionFriendUnrelatedCaretaker Name Caretaker Address Caretaker Phone Δ
