Child Application

Languages spoken (parent and child), primary language:

Parent/Guardian:

Relationship to Child:

Do you have legal custody of the child?

Yes
No

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

Yes
No

If yes, are they aware and supportive of the child's enrollment in the BBBS program?

Yes
No

Name and Phone Number of Person who shares custody:

Child's Information

Child's Name *

First

Middle

Last

Preferred Name/Nickname

Child's Gender:

Male
Female

Child's Date of Birth

What is the child's living situation?

If other living situation, please explain:

Home Phone #:

Parent/Guardian Cellphone #:

Child's Cellphone #:

Is it okay to text parent?

Yes
No

Is it okay to text child?

Yes
No

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Email:

Child Email:

Child's School:

Grade:

Teacher:

Child's Race/Ethnicity:

If Child's Race/Ethnicity is Multi-Race Check all that apply

Nationality/County or Origin:

Parent Information

Parent Place of Employment:

Parent Work Phone #:

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

Yes
No

Please check the best number and time to contact you (the parent/guardian)?

If we are unable to reach you, who is someone we could call who always knows how to reach you? List Name & Phone Number. Name:

Phone Number:

Questions

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

2. Does your child know that you are applying for the program?

Yes
No

3. Does your child want to participate?

Yes
No

4. Where did you hear about Big Brothers Big Sisters? Please check all that apply and provide details in space given.

5. Does your child have siblings or relatives who are applying for the BBBS program at this time or who are currently in the program?

Yes
No

If yes, please provide their name(s):

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

Yes
No

If yes, please explain:

7. Will your child be able to meet with his/her Big, for the required time commitment, during the next year?

Yes
No

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

Yes
No

If yes, please explain:

9. List all people (adults and children) in household and relationship to child:

10. Is the parent/guardian receiving income assistance at this time?

Yes
No

11. Is parent/guardian receiving assistance with housing (e.g., Section 8, residence in public-housing, etc.)?

Yes
No

If living in a housing development, please list the name:

12. Is child eligible for free or reduced lunch?

Yes - Free
Yes - Reduced
No

13. Household Annual Income: (total income of the adults the child lives with)

14. Does your child have a parent/caregiver with current or past military experience?

Yes
No

If yes, please list dates of service:

Branch:

Component:

Active
National Guard
Reserve

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

Is the parent retired from the military?

Yes
No

Is the parent separated/discharged (other than retired)?

Yes
No

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

Yes
No

15. Does your child have a parent/guardian who is currently incarcerated?

Yes
No

If yes, please explain:

16. Has your child ever been arrested or involved in the juvenile justice system?

Yes
No

If yes, please explain:

17. Within the last year, has your child been in any trouble at school?

Describe Behavior Problems:

Reason for suspension:

Reason for expulsion:

Reason for school change to alternative school:

18. Is there anything else you would like to share about your child and/or family?

By signing below, I certify that all of the information entered on this application is true and correct. Further, I give permission:
1. For my child to participate in the Big Brothers Big Sisters of Washington County (BBBS) program;
2. For the volunteer matched with my child, who has been screened and approved by BBBS, to transport my child to events and match activities;
3. For the school to provide social and academic information about my child to BBBS (e.g., report cards, behavior reports);
4. To have my child participate in an intake interview conducted by BBBS 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 BBBS 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 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/Sister, I agree to support my child’s match by reviewing the program and safety information given to me by BBBS, communicating with BBBS 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 BBBS staff.

Type your name here if you agree with the statement above. Your typed name will be as binding as your signature. *

First

Last

Date