Date: 4/22/2310/8/2022 Project:           Subproject:          

Status: 1st Submission Village/Town/Neighborhood:           Consent? Yes No

Child Information
Complete Name:                  
(first) (middle) (last/surname)
Child likes to be called:      
Gender: Date of Birth: (day)     (month) (year)      Estimated (exact birthday unknown)

Health: Health Comments:      

Languages spoken:         
Jobs at home:          
Religion:         
Does this person have any physical or mental limitations that will prevent him/her from fully caring for him/herself long-
term?
Could you describe the specific limitations and challenges he/she has according to the professional psychological report or
medical diagnosis?:          

Have you considered an educational plan or occupational therapy that will help them to become self-sufficient? If so,
please describe the plan:          

How is the child and family going to benefit from the sponsorship program?          

Currently attending school?: If not attending, why?

Favorite subject(s):         
Approximate distance of current school from family’s home:        
Mode of Transportation to school:          
Additional education information:          

What is your favorite thing to do? (activities, talents, pastimes)?:          

Describe the child’s personality and/or provide any additional information about the child:          

Family’s Unbound goal:          

Child’s Unbound goal:          

Page2 - Child Family Record (Project:       Subproject:       )

Child’s Complete Name:                  

(first) (middle) (last/surname)

Family Information
Mother’s name:                  
(first) (middle) (last/surname)
(if mother not present, why?):          

Occupation:      

Father’s name:                  

(first) (middle) (last/surname)
(if father not present, why?):          
Occupation:      

Other guardian name:                  

(first) (middle) (last/surname)
Relationship:           Occupation:          

Child lives under supervision of: Mother Father Other guardian

Number of brothers:     Number of sisters:    
What is unique about this family?          

Approximate monthly family income(US Dollars):          

Describe source(s) of income:          

Living Conditions
Walls:           Floor:           Roof:          

Electricity? Cooking:          

Sleeping facilities:           Has mattress: Has mat: Has blankets: Shared?:

Total number of people living in the home:   

Water supply:          
Additional information about the living situation and/or community: