Independence and Mentorship Application Form

Child Profile

Intake Form Completed *

First Name *

Last Name *

Child Birth Date *

Original Location City *

Years in Government Care: *

Most recent institution/home: *

Length of Time at Previous Home? *

Where did they live before their most recent home (foster care, a different institution, etc.)? *

Education

School Name *

Current Semester: *

Total Semesters Needed: *

Field of Study: *

Reason Field of Study Chosen: *

Current GPA: *

How do you expect your life to be seen in 10 years? What does she hope she has achieved in her career and in her life in general? *

What is their greatest strength? *

What is their greatest challenge? *

Work and Daily Life

Does the resident currently work? *

Yes

If so, what is their current job and how many hours per week do they work?

Why is the resident interested in coming to live at the Dream Home? *

What life skill (cooking, budgeting, etc.) does the resident feel will be valuable for them to learn during their time at the Dream Home? *

Who does the resident most admire and why? *

What has been their biggest accomplishment? *

What do they enjoy doing for fun or in their free time? *

What is their favorite food? *

Family History

What is the life status of the resident’s parents? *

What is the marriage status of the resident’s parents? *

Does the student have siblings? *

Yes

Sibling Details

Do they have ongoing contact with any birth family members? *

Yes

If yes, please explain:

Other Notes

Other Notes (please include any additional details the resident may have shared during the interview about their family, future, time at ICBF, career path or personality): *

Media Release

Media Release Upload *

Submit