Village Impact Project Register to be a VIP MORE ABOUT VIP Step 1 of 3 33% VIP Registration (Child Information Below)Child's Name(Required) First Last Child's Date of Birth(Required) MM slash DD slash YYYY Child's Gender(Required) Male Female Non-Binary Other Child's Ethnicity(Required) Native American Multi-Racial Native Hawaiian Other Pacific Islander Black/African American White/Caucasian Asian Latino/a Other VIP Registration (Parent/Guardian Information Below)Parent/Gaurdian Name(Required) First Last Parent/Guardian Gender(Required) Male Female Non-Binary Other Parent/Guardian Relationship to the child(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian Email(Required) Enter Email Confirm Email Home PhoneCell PhoneCan NCCJ text your cell number? Yes No NCCJ will only send you text messages about the VIP programBest time of day for a phone call Morning Afternoon Evening Please select all that applyIs the parent/guardian currently employed?(Required) Yes No Parent/Guardian Employer Employment Status Full Time Part Time Other VIP Registration (Family Information)Please list any other individuals living in your home(Required)NameGenderBirthdateRelationship to child Add RemoveHave you had any significant life changes in the past year?(Required) Yes No Do you anticipate any significant life changes in the coming year?(Required) Yes No Please specify changes in the past year Please specify changes in the coming year What is the child's current living situation?(Required)One Parent: FemaleOne Parent: MaleTwo Parent: Not MarriedGrandparentsTwo Parent: MarriedLiving with other relativeFoster HomeGroup HomeSibling GuardianOtherWhat is your estimated annual income (family)(Required) $0-$10,000 $10,001-$15,000 $15,001-$20,000 $20,001-$30,000 $30,001-$50,000 $50,001+ Does any member of your household receive family (government) assistance?(Required) Yes No Please Select all that apply Public Assistance Social Security Medicaid ADC Section 8 TANF SNAP Other Does the student qualify for free or reduced lunch?(Required) Yes No Unsure Is one or both parents currently serving in the military?(Required) Yes No Name of parent who is serving First Last Is this parent currently deployed? Yes No Is one or both parents currently serving a sentence in Federal, State, or a Local correctional Facility?(Required) Yes No Name of parent First Last Institution Name Has your child ever been involved with the juvenile Justice System?(Required) Yes No Please describe details including dates, and the nature of the involvement.
