Child Enrollment Application 1 2 3 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 household9. 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 This iframe contains the logic required to handle Ajax powered Gravity Forms.