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Youth & Parent Application
Parent's Name
*
First
Last
Child's Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Parent's place of employment
*
What is the yearly income of your family?
*
$0-10,000
$10,001-20,000
Over $20,000
Parent's Ethnicity (Check all that apply)
*
White
Black
American Indian
Hispanic
Asian
Other
Youth's Date of Birth:
*
Youth's Gender
*
Male
Female
Please list any pets in your home:
*
Email
*
Phone Number
*
Cell Number
*
Work Number
*
Best time and place to call
*
Do you receive income assistance?
*
Yes
No
Youth's Ethnicity (Check all that apply)
*
White
Black
American Indian
Hispanic
Asian
Other
Youth's Age
*
Parent's Living Status
*
Married
Divorced
Living w/ significant other
Single
Domestic Partner
Widowed
Separated
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:
Untitled
*
Other parent's name:
*
First
Last
[object Object]
Age
*
Occupation/Employer
*
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
Submit
Home
Programs
Girl Power
Volunteer
Volunteer Form
Events
Teal Lake Meltdown
Bowl For Kids' Sake 2017
Fun Run
Great Big Challenge
Donate
Enroll a Child
Youth Application
About Us
Contact
Surveys
Volunteer SOR
Youth SOR
✕
