Youth Application

List adults in child's home. (Name, age, relationship) *

Youth's School: *

List siblings or children in child's home (Name, age, relationship) *

Teacher and Grade: *

Has your child failed any grades in the past? *

Is your child involved in any school activities? *

Does your child have any school problems? *

Attitude towards school: *

Poor Fair Good Excellent

It is our policy to notify other parents and guardians that you have applied your child to be in the Big Brothers Big Sisters program, if they live in the area. If there is any reason you object to this, please explain:

Address *

Line 1

Line 2

City

State

Zip Code

Country

Is the other parent in contact with the child? *

Has the child accepted the other parent's absence? *

Phone Number *

Does he/she share custody? *

Yes No

Is he/she aware of the child's enrollment in BBBS? *

Yes No

Describe any physical problems your child has: *

Is your child allergic to anything? Please list: *

Describe your child's behavior and personality: *

What is the primary reason for you wanting your child to have a Big Brother/Big Sister? *

Is your child on any medication? Please list: *

Is your child reveiving any counseling? If yes, please list counselor: *

List your child's interests: *

I give permission for my child to participate in the Big Brothers Big Sisters program. I understand that the BBBS agency is not obligated to match my child with a volunteer and that as part of the enrollment process I will be asked to provide additional personal information. If my child is matched with a Big Brother or Big Sister I agree to support my child's mtch and to immediately report any concerns I might have to the Big Brothers Big Sisters staff.

Please check I agree to verify that you have read and agree to the above statemtn *

I agree

Youth & Parent Application