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Placement Request

Placement Request

The Baptist Children’s Village is here to take the good news of Jesus Christ to at-risk Mississippi children and families. You have a Savior. In HIM there is HOPE.

You may request placement of a child or children into our residential program or request help for a family through our In-Home Family Support Program by filling out the form fields below. Fields marked with an * are required. Someone from our social services office will follow up with you.

Person or Agency Making Request *

Name *

Address *

City *

State *

Zip Code *

Mississippi County from which the child(ren) are being referred *

Email Address

Phone Number *

Program Application *

Child #1 Full name, Age, and Date of Birth *

Child #2 Full name, Age, and Date of Birth

Child #3 Full name, Age, and Date of Birth

Child #4 Full name, Age, and Date of Birth

Child #5 Full name, Age, and Date of Birth

Reason for placement *

Leave this field blank

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