Child Enrollment Application 1 2 3 4 Parent/Guardian*Relationship to child*Do you have legal custody of the child?*YesNoIs there a person who shares legal custody of this child?*YesNoIf yes, are they aware and supportive of the child’s enrollment in the BBBS program?:*YesNoName*Phone Number Child’s Name* First Middle Last Preferred Name/Nickname*Child’s Gender*MaleFemaleChild Date of Birth* What is the child’s living situation?* Two-(biological) parent household One-(biological) parent household Other relative of child (non-parent) Foster Home Group Home Other One-(biological) parent household*MaleFemaleIf other, pls specifyHome Phone NumberParent Cell Phone NumberChild Cell Phone NumberIs it okay to text parent?YesNoIs it okay to text child?YesNoCell ProviderCell ProviderAddress Street Address City State / Province / Region ZIP / Postal Code Parent/Guardian Email Child Email Child’s School*Grade*Extracurricular Activities*Child’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 Nationality/Country of Origin*Parent Place of Employment*Parent Work Phone NumberMay we contact you (the parent/guardian) at the work number listed above?*YesNoPlease check the best number and time to contact you (the parent/guardian)?* Home Morning Cell Afternoon Work Evening 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 child to have a Big Brother or Big Sister?*2. Does your child know that you are applying for the program? Does your child want to participate?*3. Where did you hear about Big Brothers Big Sisters? Please check all that apply and provide details in space given.* School Relative Faith Organization Service Organization Website TV/Radio Event Other Pls specify4. Does your child have siblings or relatives who are applying for the BBBS program at this time or who are currently in the program?*YesNoIf yes, please provide their name(s)5. Do you anticipate any significant life changes over the next year or have you had any in the past year, such as moving?*YesNoIf yes, please explain6. 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?*YesNo7. Does your child have any medical conditions that might affect him or her participating in activities with a Big Brother/Big Sister?*YesNoIf yes, please explain8. Number of people (adults and children) in household*9. Is the parent/guardian receiving income assistance at this time?*YesNo10. Is parent/guardian receiving assistance with housing (e.g. Section 8, residence in public-housing, etc.)?*YesNoIf living in a housing development, please list the name11. Is child eligible for free or reduced lunch?*Yes - FreeYes - ReducedNo12. Household Annual Income: (total income of the adults the child lives with)*0 - $10,000$10,001 - $15,000$15,001 - $20,000$20,001 - $30,000$30,001 - $50,000$50,001+13. Does your child have a parent/caregiver with current or past military experience?*YesNoIf yes, please list dates of service: Branch: Air Force Army Marine Corps Navy Coast Guard Component: Active National Guard Reserve Is the parent currently deployed?*YesNoIf yes, place the date of deployment: Is the parent retired from the military?*YesNoDoes your child have a parent/caregiver that is considered fallen, wounded or disabled?*YesNo14. Does your child have a parent/guardian who is currently incarcerated?*YesNoIf yes, please explain15. Has your child ever been arrested or involved in the juvenile justice system?*YesNoIf yes, please explain16. Within the last year, has your child been in any trouble at school?* Poor Grades Skipping school/classes Truant Behavior problems Has been suspended Has been expelled Sent to an alternative school Describe the behavior problemsReason for suspensionReason for expulsionReason for school change By signing below, I give permission: For my child to participate in the Big Brothers Big Sisters Program; 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; For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports); 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; To have my child talk with a Big Brothers Big Sisters staff person about personal safety; 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.Sign*Type Your NameDate* This iframe contains the logic required to handle Ajax powered Gravity Forms.