Halo Program
Thank you for seeking out the HALO Program for your family. We are honored that you would trust us to meet your family’s needs. It is our belief that you will find the answers you are looking for in this program.

**Please note, we are only able to service kiddos ages 4-8 at this time.**

Once you fill out the application below, you will be added to our wait list and should receive a confirmation email within 24 hours.
Sign in to Google to save your progress. Learn more
Number of Primary Caregivers
Caregiver #1 First and Last Name *
Caregiver #1 Email *
Caregiver #1 Phone Number *
Is it okay to text this number?
Home Address
Caregiver #2 First and Last Name
Caregiver #2 Email
Caregiver #2 Phone Number
Is it okay to text this number?
Clear selection
How did you hear about this program? *
Child's First and Last Name *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Age
Child's Sex/Gender *
Child's T-Shirt Size *
Parent #1 T-shirt size
Clear selection
Parent #2 T-shirt size
Clear selection
Type of Insurance (Primary and/or Secondary): *
DCS Worker's Name (If Applicable)
DCS Worker's Number (If Applicable)
Foster Care Agency (If Applicable)
In families with more than one caregiver, are both caregivers and child able to meet in the evening one night a week for 10 weeks from 6:00-8:00?  Caregivers will participate in Trauma Education Classes while the target child participates in Kids' Club. *
Are you able to arrange childcare for your other kiddos (if applicable) while the rest of the family is at Halo night? *
Do you and your child/teen agree to counseling sessions once a week during the day? The sessions will likely be held between the hours of 8:15 am and 3:00 pm. The day of the week varies. In families with multiple caregivers, both caregivers will be asked to participate as much as possible.
 *
If your child is in foster care, are they likely to be unified with their biological parents before the completion of the project?
 *
Caregivers, please be aware that your name will be on the Halo Program waitlist which is monitored by more than one member of the Village To Village staff. Is this ok?
 *
Is the child/teen receiving counseling services at another agency?
 *
What other services have you participated in?
Explain why you think Halo Program would be helpful for you and your family.
If you attend church regularly, which church do you attend?
Is there anything else you would like us to know?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms