Name

Relationship to Child

Do you have legal custody of the child?
YesNo

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

Name of person with shared custody

Phone number of person with shared custody

First Name

Last Name

Middle Name

Preferred Nickname

Gender
MaleFemale

Date of Birth

Home Phone Number

Parent Cell Phone

Okay to Text Parent

Parent Cell Provider

Child Cell Phone

Okay to Text Child

Child Cell Provider

Address

City, State & Zip

Parent Email

Child Email

School Attending

Grade

Extracurricular Activities

Child's Race/Ethnicity:

Parent Employer

Parent Work Phone

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

What time and number is best to contact you?

If we are unable to reach you, who is someone we could call who always knows how to reach you?

Contact Phone Number

Relationship to you?

Background Information

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

Does your child know that you are applying for the program? Does your child want to participate?

Where did you hear about Big Brothers Big Sisters?

Does your child have siblings or relatives who are applying for the BBBS program at this time or who are currently in the program? If yes, please provide their name(s).

Do you anticipate any significant life changes over the next year or have you had any in the past year, such as moving? If yes, please explain.

Will your child be able to meet with their Big [once a week or every other week in the evenings or on the weekends] for the next year?

Does your child have any medical conditions that might affect him or her participating in activities with a Big Brother/Big Sister? If yes, please explain.

Number of people (adults and children) in household:

Income Assistance
YesNo

Is parent/guardian receiving assistance with housing (e.g. Section 8, residence in public-housing, etc.)? If living in a housing development, please list the name:

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

Is child eligible for free or reduced lunch? If yes, please specify:

Does your child have a parent/caregiver with current or past military experience? If yes, please list dates of service:

What Branch?

What Component (Active, National Guard, Reserve)?

Is the parent currently deployed? If yes, please the date of deployment:

Is the parent retired from the military?

Does your child have a parent/caregiver that is considered fallen, wounded or disabled?

Does your child have a parent/guardian who is currently incarcerated? If yes, please explain:

Has your child ever been arrested or involved in the juvenile justice system? If yes, please explain:

Within the last year, has your child been in any trouble at school with poor grades?

Within the last year, has your child been in any trouble at school with skipping school/classes?

Within the last year, has your child been in any trouble at school with truancy?

Within the last year, has your child been in any trouble at school with behavior problems? If yes, please explain:

Within the last year, has your child been in any trouble at school with suspensions? If yes, please explain:

Within the last year, has your child been in any trouble at school with expulsion? If yes, please explain:

Within the last year, has your child been sent to an alternative school? If yes, please explain the reason for change:

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.

Parent/Guardian Signature

Date of Acceptance