Families of Victory

Contact
Us

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Intake Form

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1. Parent/Guardian Information

Please provide the primary parent/guardian’s contact details.

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Parent/Guardian Full Name *

Email Address *

Phone *

City/State *

2. Participant (Child/Youth) Information

Tell us about the child or youth who will attend.

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Name (Participant Full Name) *

Number (Age 8–18) *

Gender *MaleFemale

Age Group *8–1213–1516–18

3. Emergency Contact

Provide an additional contact in case of emergency.

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Emergency Contact Name *

Emergency Contact Phone *

Relationship to Participant *

4. Session Interests & Background

Select focus areas and share anything helpful for our mentors.

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Areas of Interest for ParticipantIdentity in Christ & Biblical Self-WorthFriendship, Peer Pressure & Decision-MakingRespect, Responsibility, and Emotional RegulationBullying, Boundaries & Self-ControlAcademic Encouragement & Goal SettingLeadership, Community Impact & Purpose DiscoveryPrayer, Worship, and Daily Faith LivingOther

How did you hear about COPS?WebsiteSocial MediaChurchSchoolFriend/ReferralCommunity EventOther

Any special needs, prayer requests, or additional information about your child

5. Consent & Agreement

Parent/guardian permission is required to participate.

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I give permission for my child to participate in the Families of Victory – Children of Promise Empowerment Sessions. I understand that these sessions are faith-based, structured, and facilitated by certified mentors and advisors. *

Submit