Information on Child

If applicant is from Elkhart and has questions, call (574) 830-5013 for more information

    Do you have legal custody of the child?
    YesNo

    Is there a person who shares legal custody of this child?
    YesNo

    Gender
    MaleFemale

    May we contact you (the parent/guardian) at the work number listed above?
    YesNo


    Background Information

    Income Assistance
    YesNo

    Household Annual Income
    0-$10,000$10,001-$15,000$15,001-$20,000$20,001-$30,000$30,001-$50,000$50,001+


    Disclosure/Permission

    By signing below, I give permission:

    1. For my child to participate in the Big Brothers Big Sisters Program;
    2. For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to transport my child to
    events and match activities;
    3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior
    reports);
    4. To have my child participate in an in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires
    throughout his/her time in the program containing questions about school, home life, and personal interests;
    5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
    6. For BBBS staff to provide contact information for me and my child to the volunteer.

    I understand that the program 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 information through an in-person interview. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information relevant to child-safety and well-being).

    I certify that all of the information on this form is true and correct and that all income is reported. I understand this information could be given for the receipt of funding, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my qualification for the program.

    I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me as his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable.

    If my child is matched with a Big Brother or Big Sister I agree to support my child’s match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff as outlined in expectations (which includes communication at least once a month in the first year of the match), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.