REFER A CHILD

Thank You for recognizing and referring a child who has experienced a devastating situation and is in need of Emotional Stability and/or Long-Term Functional solutions that will increase their quality of life. Please understand that Submitting an Application DOES NOT ensure you will be selected. We receive many more applications than we can provide services for. You will be contacted by phone within 7 days of your submission if you meet the following 5 MANDATORY REQUIREMENTS:

1. You Must OWN YOUR HOME – for legal liability, we cannot do modifications or renovations

      on rental properties, even with the consent of the property owner.

2 Child Must be a LEGAL RESIDENT of the United States

3. You Must have LEGAL GUARDIANSHIP OF THE CHILD being Referred

4 Child Must be UNDER 18 years old; (adults over 18 who have a much younger mind cannot be considered)

5. Until 2020, we will only be able to approve children in BLOUNT COUNTY, TN. ONLY.  Surrounding counties will be considered as our organization grows.

Today's Date
Today's Date
Name of Child *
Name of Child
Gender *
Birthday
Birthday
RESIDENCE
Name of Parents or Legal Guardians
Name of Parents or Legal Guardians
Parent's/Legal Guardian's Phone Number
Parent's/Legal Guardian's Phone Number
Parent's/Legal Guardian's Address
Parent's/Legal Guardian's Address
Is Child's Primary Residence the same as Parents/Legal Guardian?
If Yes, do Parents/Legal Guardians OWN this home?
List secondary address:
List secondary address:
Are there other EXTENDED FAMILY members who live in the home?
Is the child an American citizen?
Does the child have siblings?
Do the siblings live with the child?
EDUCATION
Does the child attend school?
Does the child have developmental delays or learning disabilities?
Does the child have an IEP (Individualized Education Plan)?
Is the child in a CDC classroom?
Do the siblings attend the same school?
VULNERABILITY
KDM seeks to help children who have faced devastation and whose family is in a vulnerable situation.
Does your family have health/medical insurance?
Is insurance provided by mother's, father's, or guardian's job?
Is insurance provided by the State of Tennessee?
Does your child require services, such as therapy, that insurance does NOT cover?
DEVASTATION
Please describe the TYPE OF DEVASTATION or tragedy the child has faced. Please include physical, mental, intellectual, and emotional issues.
Does the child talk?
Can the child eat regular solid food?
Can the child fed himself?
Can the child walk on his own?
Is the child in a wheelchair?
Does the child use a walker?
Can the child sit up and balance himself on his own?
Does the child require 24/7 care from a nurse or professional outside the home?
If yes, are they reliable to show up?
Can the child potty on his own?
Does the child wear diapers for medical reasons?
Does the child's body temperature have to remain constant (or close)?
Do you experience the physical difficulty of lifting your child into bathtub, onto potty?
Do you see a chiropractor for back/neck pain?
Are you able to easily transfer your child to/from bed?
If yes, how do you currently achieve this?
Are you able to easily transfer your child to/from the car?
Do you have a vehicle that is handicap accessible?
ACCESSIBILITY
If the child is in a wheelchair or walker, can they get through the door of the bathroom?
Can the child get into the bathtub on their own?
Can the child move freely about their bedroom?
Is your home handicap accessible?
Do you need a handicap ramp to get the child into the house?
Does your child have access that would allow them to get out of their bedroom in case of emergency?
Would wider doorways be helpful to increase child’s mobility inside the home?
Would your home require some renovation/construction in order to achieve handicap accessibility?
Do you have working smoke detectors in your home?
Do you have working carbon monoxide detectors in your home?
DESIGN
Does the child have sensory/tactile issues?
ADDITIONAL COMMMENTS
The Makeovers/Renovations that KDM provides are given to the family, AT NO CHARGE, as a Gift of Love - No strings attached. We do NOT ask the family to work on the Project, nor to contribute financially.
ACCEPTANCE
If your child is chosen, are you willing to accept KDM's Free Gift of Love, knowing that it is a Christian Ministry and there will likely be prayer conducted inside your home?