Youth Inquiry Form 1 2 3 4 Parent/Guardian*Parent/Guardian primary language spoken*Relationship to youth*Youth primary language spoken*Do you have legal custody of the youth?*YesNoIs there a person who shares legal custody of this youth?*YesNoIf yes, are they aware and supportive of the youth’s enrollment in the BBBS program?:*YesNoName of person sharing custody*Phone Number Youth’s Name* First Middle Last Preferred Name/Nickname*Youth’s Gender*MaleFemaleYouth's Date of Birth* Parent/Guardian Cell Phone NumberIs it okay to text parent/guardian?YesNoParent/Guardian Cell ProviderYouth Cell Phone NumberIs it okay to text youth?YesNoYouth Cell ProviderAlternate Phone NumberHome Address Street Address City State / Province / Region ZIP / Postal Code How did you hear about Big Brothers Big Sisters of Elkhart County? School Website TV/Radio Event Relative Faith Orginization Service Orginization Other Please specifyYouth’s School*Youth's Grade Level*Parent/Guardian Email Youth’s Race/Ethnicity*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOtherMulti-raceMulti-race (check all that apply) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Parent/Guardian Place of Employment*Parent/Guardian Work Phone NumberMay we contact you (the parent/guardian) at the work number listed above?*YesNoPlease check the best number & time to contact you (the parent/guardian)* Home Cell Work Morning Afternoon Evening Is there a specific time that works best for you? If so, please list below.If we are unable to reach you, who is someone we could call who always knows how to reach you?Name*Phone Number*Relationship to you* 1. What is the primary reason for you wanting your youth to have a Big Brother or Big Sister?*2. Does your youth know that you are applying for the program? What are his or her feelings about having a mentor?*3. Describe your youth’s personality, strengths and talents.*4. How does your youth spend his or her time? What activities does he/she enjoy?*5. Does your youth prefer to be active and participate in activities or to sit back and observe?*6. Describe a person you think would meet your youth’s needs and interests.*7. What skills or areas do you want a volunteer to help your youth with or teach your youth?*8. What agencies/organizations does your family/youth participate in or receive services from?*Please check the box that your youth may have interest in (or currently involved in). Cards Board Games Video Games Listening to Music Movies Plays/Theatre Singing Cheerleading Crafts Scrapbooking Knit/Sew/Crochet Shopping Picnics Parks Walking Bowling Golf Ping Pong Billards Tennis Skating Bike riding Horseback riding Swimming Boats Camping Fishing Hunting Skiing Dancing Art Playing Music Reading Politics Gardening Choir Baking/Cooking Gymnastics Hair/Makeup Photography Electrical Mechanical Woodworking Cars Animals History/Social Studies Literature Math Science Gym Computers Band/Orchestra Baseball/Softball Basketball Football Hockey Track Volleyball Soccer Skateboarding Thank you for your interest in Big Brothers Big Sisters of Elkhart County! Please know that professional staff matches each youth with a mentor based on similar interests, personality and location of the youth. This process is not based on a “first come, first serve” method but instead a process is used that matches all youth and mentors individually based on the needs of the youth. *** During the inquiry period we will invite all youth to participate in events. At the events, photo’s may be taken to be used on social media, newsletters, and outreach. ** Please indicate below if you wish to authorize the discretionary use of your youth’s photograph and/or personal information to be used by Big Brothers Big Sisters of Elkhart County, Inc. for the purpose of promoting/advertising said program. Photo Permission*YES, I give permission for my youth’s photograph to be usedNO, my youth’s photograph may not be used.By signing below, I give permission: For my youth to participate in the Big Brothers Big Sisters Program; For the volunteer matched with my youth, who has been screened and approved by Big Brothers Big Sisters, to transport my youth to events and match activities; For the school to provide social and academic information about my youth to Big Brothers Big Sisters (e.g. report cards, behavior reports); To have my youth 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; To have my youth talk with a Big Brothers Big Sisters staff person about personal safety; For BBBS staff to provide contact information for me and my youth to the volunteer. I understand that the program is not obligated to match my youth 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 youth abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my youth will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information relevant to youth-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 youth 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 youth 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 youth is matched with a Big Brother or Big Sister I agree to support my youth’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.Sign*Type Your NameDate* This iframe contains the logic required to handle Ajax powered Gravity Forms.