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CBC Profile Questionnaire by htt39969


									                    CBC Profile Questionnaire (2007)
Participant’s Last Name ____________________ First Name_____________________ Middle Initial ____

Address ____________________________________________________________ Apt. # _______________

City ______________________________                  State ______________        Zip ______________________________

Home Phone (______)________________________                             Alternate Phone (_____)__________________

School ____________________________________                             Grade ________________________________

Age ______            Birthday _____/_____/______                       Sex (Circle One)     Male / Female

                                    mo         day     year

Race:    (Circle)     African American / American Indian / Caucasian / Hispanic / Other _________________

Height _________             Weight _________                 Pant Size ______        Waist Size in inches __________

Shirt Size:   (circle one)      SMALL / MEDIUM / LARGE / 1X / 2X / 3X

We recognize that the following questions may seem personal in nature; but we feel the
information is vitally important in order for us to help your child. This questionnaire will
help us get to know more about your child, your family, and the environment from which
your child comes. It will also help us to know how we can minister to your child more
effectively and locate areas of weakness, so that your family can be strengthened through
prayer and other practical means. This questionnaire will be kept in strict confidence, so
please feel free to answer the questions as openly and honestly as possible.

     Note: Bring the following completed paperwork to your interview appointment:
                              (See cover letter or flyer for dates / call to schedule 15 min. interview time)

                                               Bring this form - CBC Profile Questionnaire
                                               Parental Consent / Medical Information Form
                                                          Copy of shot records
                                                  Your Registration Payment of $500

                                     Christian Boot Camp (CBC)
                                      “Rescuing a Generation”
                                                     Love Demonstrated Ministries, Int’l
                                                          Post Office Box 28359
                                                       San Antonio, TX 78228 –0359
                                               Phone (210) 431-3CBC / (210) 415-7551
                                                         Fax: (210) 431-0570
                                               Email address: LDMICBC @ AOL.COM
Parent Information

Name __________________________________________________________________________

Address __________________________________________________                        Apt. #    ________

City _________________________________                State ____________          Zip Code _______

Home phone # (        ) __________________            Work phone # (         ) __________________

              Participant Information                              Fill out this section with your child

Circle your Sports & Interest:                                     Favorite Things: (Name them on the line provided)

Baseball   Karate        Soccer                                    Favorite kind of books to read          __________

Football   Basketball Tennis                                       Favorite kind of music                  __________

Swimming            Track / field                                  Favorite places to go                   __________

Volleyball Other __________________________                        Favorite role model                     __________

1. What do your friends like most about you? ___________________________________________________________________

2. What do you like most about yourself?     _____________________________________________________________________

3. How do you feel about your parent(s)?     _____________________________________________________________________

4. List two good qualities about your parent(s) ___________________________________________________________________

5. How would you describe your relationship between you and your parents / guardian? Excellent / Good / Fair / Poor / Very Poor

6. What would you say is the main source of conflict between you and your parent(s), if any?

Explain: _________________________________________________________________________________________________

7. What would you say is the greatest challenge in your life at this time?

Explain: _________________________________________________________________________________________________

8. What are your goals in life? ______________________________________________________________________________

9. Do you believe in God? Yes / No / Unsure

10. Do you have a relationship with God? Yes / No / Unsure

11. Do you come from a religious background? Yes / No

12. What is your religious affiliation? Christian / Catholic / Mormon / Jehovah’s Witness / Muslim / None / Other ____________
                                               Household Information
                                                To be filled out by parent(s):

Marital Status?                                       Married (w/ two parents in home) Widowed / Single
                                                      Separated / Divorced

Which parent(s) lives at home?                        Both Father & Mother      Only Father                 Only Mother
(circle one)                                          Stepfather & Mother       Father & Stepmother         Foster Parents
                                                      Adoptive Parents / Mother/live in boyfriend / Father/live in girlfriend
                                                      Grandparents / Grandmother / Grandfather / Other ___________

Number of parents in the home?                        1           2

How many children do you have?                        1           2          3        4        5        other ________

How many children live with you?                      1           2          3        4        5        other ________

What are the ages of the children that live in your home?         _____      _____    _____    _____    _____

What # child is the applicant?                        1st born        2nd born   3rd born   4th born   other ____

Do you feel your household is under control?          Most of the time / Sometimes / Hardly ever

Are you as a parent, willing to attend family classes to help strengthen your family?          Yes      No

                                        Child Behavioral Information

Are you having difficulties with your child?          No difficulties / Yes, minor difficulties / Yes, major difficulties

Please discuss any difficulties that you may be having with your child such as: rebellion, depression, combative behavior,
anger, A.D.H.D, etc.         (please be specific) [you may use another sheet of paper if necessary]

Are there any stressful family situations that may have contributed to your child’s difficulties, such as death of family
member, divorce or separation, incarceration of a family member, drug or alcohol use by a family member, sexual abuse,
physical abuse?

Please explain:

Are there any neighborhood situations that may have contributed to your child’s difficulties such as peer pressure, drugs,
gangs, alcohol, etc. Please explain:

What are some of your child’s greatest strengths? __________________________________________________________

                                Child Behavioral Information (Cont’d.)

Does your child smoke cigarettes?                                 Yes     No         Unsure

Has your child ever used drugs or any illegal substance?          Yes     No         Unsure

If yes, which ones?                         alcohol               marijuana          paint sniffing   Other ____________

What is your child’s attitude about attending CBC? Excited, thinks it will be a challenge, and wants to meet the challenge

                                                      Slightly Reluctant / Strongly opposed and doesn’t want to come

Has your child ever run away from home? No        Yes        If yes, how many times? _______
Where did he / she go? _____________________________ Why did he / she run away? ___________________________

                                            Medical Information
**Please note – CBC is a very physically strenuous program and your child will be required to run, jump, do push ups,
sit-ups and other activities. If your child has any health problems please consult with your doctor to be sure that this
program is right for your child!

1. Does you child have any medical problems that would prohibit him / her from participating in CBC?         YES       NO

If yes, please explain:

2. Is your child currently taking any doctor prescribed medications?           YES     NO

If yes, please explain:

                         CBC Medical Information paperwork must be filled out.
                        Regular athletic physical paperwork will not be accepted!

         Please read and sign carefully! In signing this CBC Profile Questionnaire:
   I do certify that the information that I have given is true and accurate to the best of my knowledge.

   I agree to attend the following Christian Boot Camp Family Conferences:

                          Fall Conference –   Sep. 13th – 15th , 2007         (Thurs. & Fri. 7-9 PM) (Sat. 10 AM – 2PM)
                          Winter Conference – Dec. 6th – 8th , 2007           (Thurs. & Fri. 7-9 PM) (Sat. 10 AM – 2PM)
                          Spring Conference – Mar. 27th – 29th, 2008          (Thurs. & Fri. 7-9 PM) (Sat. 10 AM – 2PM)

   I also agree to the terms of the refund policy stated in the CBC 2007 flyer.

                                If both parents are in the home, both sign please!
Participant’s Signature         ____________________________________                                  Date ____________
Parent / Guardian Signature ___________________________________                                       Date ____________
Parent / Guardian Signature ___________________________________                                       Date ____________

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