Student Application

Applying for Placement

The form below is to gather information that will help us to know if our program is the right fit for you and your teen. Our program is designed for teen girls between 12 and 18 years old of age a student younger will not be considered at this time.
Student Info
Student's Full Name*

First NameMiddle NameLast Name
Nickname
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth
Grade
What school does your daughter currently attend?
Where is current school located?
Please provide a current transcript or yearly report card.

Browse Files

Cancelof
Name of Church if student or students family is currently attending:
Parental/Guardian Info
Parent/Guardian 1

First NameLast Name
Relationship to Student
YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail*
Occupation
Marital Status
Parent/Guardian 2

First NameLast Name
Relationship to Student
YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Occupation
Marital Status
Background of Student
RunawayTobaccoAlcoholDrugsPornagraphyStealingSexually ActiveAbuseViolenceCutting/Self harmEating DisordersSchool Behavioral Problems
YesNo
YesNo
Yes, student knowsNo, student does not know
Please describe the family dynamic. (ex. divorced, single parent, blended family, siblings, etc.)
Please give a brief summary of student's history (ex. adopted, abuse, trauma, etc.)
Please describe why you are considering placement in a boarding school. (Be specific)
Please indicate the corrections you have tried with the student and was it successful or unsuccessful.
Describe student's school performance.
What activities or hobbies does your student enjoy?
What are your student's strengths?
What is your number one goal for your student if admitted to VVCA?
Is student currently on medication? If so, what is the purpose of the medication?
How did you hear about Victory Village?
Any additional info
Best way to contact you for additional information?
Enter the message as it's shown*
By clicking Submit you are virtually signing and stating that the information you have provided in this application is correct to the best of your knowledge.
Should be Empty:

Applying for Placement

Student Info

Parental/Guardian Info

Background of Student