Non-Discrimination Policy
Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.
CHILD APPLICATION
Agency Location & Program Selection
Please select the county in which you reside:
Please select...
Carroll
Clark
Cuyahoga
Delaware
Fayette
Franklin
Harrison
Highland
Madison
Morrow
Pickaway
Pike
Ross
Tuscarawas
Union
Central Ohio Programs
Program Descriptions
Community-Based
:
Matches meet one-on-one out in the community 2 times a month.
School-Based Plus:
Matches meet out in the community as well as in their school setting.
School-Based Facilitated:
Matches meet in a supervised school setting during the day or after-school. Bigs and Littles may not communicate outside of school mentoring sessions.
Which Central Ohio Program are you interested in enrolling your child in?
Community Based
School Based Plus
School Based
East Central Ohio Programs
Program Descriptions
Community-Based
:
Matches meet one-on-one out in the community 2 times a month.
School-Based Plus:
Matches meet out in the community as well as in their school setting.
School-Based Facilitated:
Matches meet in a supervised school setting during the day or after-school. Bigs and Littles may not communicate outside of school mentoring sessions.
Which East Central Ohio Program are you interested in enrolling your child in?
Community Based
School Based Plus
School Based
South Central Ohio Programs
Program Descriptions
Community-Based
:
Matches meet one-on-one out in the community 2 times a month.
School-Based Facilitated:
Matches meet in a supervised school setting during the day or after-school. Bigs and Littles may not communicate outside of school mentoring sessions.
Which South Central Ohio Program are you interested in enrolling your child in?
Community Based
School Based
Greater Cleveland Programs
Program Descriptions
Community-Based
:
Matches meet one-on-one out in the community 2 times a month.
Which Greater Cleveland Program are you interested in enrolling your child in?
Community Based
Child's School
Please select...
Carrollton MS
Conotton Valley ES
Conotton Valley MS
Malvern ES
Malvern MS
Big Walnut ES
Conger ES
Dempsey MS
Prairie Run ES
Woodward ES
Africentric Early College
Arts Impact MS
Buckeye MS
Hamilton STEM
Highland ES
Livingston ES
Prairie Norton ES
Windsor STEM
Harrison Hills City Schools
Greenfield Exempted Village School
London ES
Cardington MS
Mt. Gilead ES
Circleville City Schools
New Hope Christian Academy
Teays Valley LSD
Westfall LSD
Waverly Intermediate
Adena ES
Southeastern ES
Unioto Middle School
Zane Trace LSD
Claymont Intermediate
Dover Avenue ES
Dover East ES
Dover Middle School
Dover South ES
Indian Valley MS
New Philadelphia East ES
New Philadelphia South ES
New Philadelphia West ES
Newcomerstown West ES
Strasburg ES
Strasburg MS
Tuscarawas Central Catholic Schools
Tusky Valley Elementary
Tusky Valley MS
If your child's school is not available please select the community-based program.
Hidden Fields
Youth Contact Owner Email
For notifications
Youth Contact ID
Youth Enrollment ID
Additional Youth Found
Yes
No
Stage:
CHILD APPLICATION
All information on this application is confidential. We use this information to assist in matching your child and for grant funding only.
Child Information
Youth First Name
Youth Middle Name
Youth Last Name
Suffix
e.g. Jr, III
Preferred Name
Birthdate
Enter a date in the following format: mm/dd/yyyy
Gender
Please select...
Male
Female
Trans Male
Trans Female
Genderqueer/Nonbinary
Different Identity
Prefer not to say
Personal Pronouns
Please select...
He, Him
She, Her
They, Them
Other pronouns
How does the child identify?
What pronouns does the child use?
Race/Ethnicity
Please select...
American Indian or Alaska Native
Asian - Chinese
Asian - Filipino
Asian - Indian
Asian - Japanese
Asian - Korean
Asian - Other
Asian - Vietnamese
Black or African American
Hispanic - Cuban
Hispanic - Mexican, Mexican American, Chicano
Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican
Middle Eastern or North African
Pacific Islander - Chamorro
Pacific Islander - Native Hawaiian
Pacific Islander - Other
Pacific Islander - Samoan
White or Caucasian
Other
Prefer not to say
Press CTRL while choosing to select multiple
School
Graduation Year
Please select...
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
Use
THIS LINK
to determine graduation year by grade.
Does the child have their own phone?
Yes
No
Child's Phone
Enter numbers only starting with area code
Does the child have their own email address?
Yes
No
Child's Email Address:
National Origin: Is the child an immigrant/refugee?
Yes
No
Please list child's country of birth
Has the child ever been involved with the police or juvenile justice system?
Yes
No
What was their involvement?
Does the child have a parent/guardian who is currently incarcerated?
Yes
No
Which parent/guardian is incarcerated?
Mother
Father
Step-Mother
Step-Father
Child Living Situation
Please select...
Two Parent
One Parent: Female
One Parent: Male
Other Relative
Group Home
Foster Home
Institution
Grandparents
Sibling Guardian
Two Parent: Not Married
Two Mothers
Two Fathers
Other/Unknown
Living Situation Description
Does the child have a parent/guardian who is serving or served in the military?
Please select...
No
Yes: Active
Yes: Gold Star
Yes: Reserves
Yes: Retired/Vet
Is the child's parent/guardian currently deployed?
Yes
No
Guardian Information
Guardian Contact ID
Guardian's Relationship to Youth
Please select...
Mother
Father
Step-Mother
Step-Father
GrandMother
GrandFather
Aunt
Uncle
Relative: Other
Foster Parent
Teacher
Counselor
Clergy
Probation Officer
Non-Relative: Other
Self-Emancipated Minor
Social Worker-Case Mgr
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Birthdate:
Input format: mm/dd/yyyy
Preferred Language:
English
Spanish
African Languages (Swahili, Bantu)
American Sign Language
Arabic
Asian: Other
Chinese
Creole
Dutch
Eastern European (Czech, Slovak)
French
German
Greek
Hebrew
Hmong
Indian (Hindi, Punjabi)
Italian
Japanese
Keres (West)
Korean
Nordic
Persian
Portuguese
Russian
Turkish
Lao
Mobile Phone
Enter numbers only starting with area code
Home Phone
Enter numbers only starting with area code
Work Phone
Enter numbers only starting with area code
Work Phone Ext
Preferred Phone
Please select...
Home
Work
Mobile
Other
Best Time to Call
Please select...
Anytime
Daytime
Evening
Weekend
Personal Email
Work Email
Alternate Email
Preferred Email
Please select...
Personal
Work
Alternate
Contact Preference
Please select...
Phone
Email
Text/SMS
Employer
Type NA if unemployed
Is there a person who shares custody of this child?
Yes
No
Custody is shared with:
Family Information
Mailing Street Address
Mailing City
Mailing State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Mailing Zip Code
Mailing County
Please select...
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Knox
Lake
Lawrence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
Please check here if your mailing address is different from your residential address:
Physical Address
Street Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Annual Household Income
Please select...
Less than $10,000
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $44,999
$45,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $199,999
$200,000 or more
Unknown
How many people are currently living in your household?
Is the child eligible to receive free/reduced lunch?
Yes
No
Does your family receive income assistance?
Yes
No
Do you anticipate any significant life changes over the next year, or have you had any in the past year?
Yes
No
Please Describe:
Has your child had any involvement with your local children's service agency?
Yes
No
i.e Franklin County Children's Services
Existing Household Members
Please choose this child's relationship to the following people:
Name:
Relationship:
Please select...
Brother
Sister
Sibling
Cousin
Other
App record ID
contact record ID
Emergency Contact
In the event you cannot be reached please provide an emergency contact:
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone
Emergency Contact Relationship to Youth
Please select...
Aunt
Brother
Clergy
Counselor
Cousin
Family
Father
Foster Father
Foster Mother
Foster Parent
Friend
Grandfather
Grandmother
Grandparent
Mother
Neighbor
Non-Relative: Other
Parent
Probation Officer
Relative: Other
Sibling
Sister
Social Worker-Case Mgr
Step-Father
Step-Mother
Step-Parent
Teacher
Uncle
The following information will help assist us in matching your child to a screened Big (volunteer).
Is the child taking any medications?
Yes
No
Medications Description
Does the child have any allergies?
Yes
No
Allergies Description
Child's Mental Health Diagnoses
:
None
Agoraphobia
Anxiety/Panic
Bipolar Disorder
Depression
Obsessive Compulsive Disorder (OCD)
Oppositional Defiance Disorder (ODD)
PTSD
Schizophrenia
Suicidal Ideation
Tourette Syndrome
Other
Check all that apply
Other - please describe:
Child's Developmental Diagnoses
:
None
ADD
ADHD
Asperger’s Syndrome
Autism
Dyslexia
Cerebral Palsy
Hearing Impairment
Intellectual Disability
Learning Disability
Memory Loss
Traumatic Brain Injury
Visual Impairment
Other
Check all that apply
Other - please describe:
Child's Exposure to Trauma
:
None
Alcohol Addiction
Bullying
Community Violence
Death of a Parent
Domestic Abuse
Drug Addiction
Emotional Abuse
Homelessness
Neglect
Physical Abuse
Sexual Abuse
Other
Check all that apply
Other - please describe:
Chronic Illnesses:
None
Cancer
Chronic or Acute Asthma
Diabetes
Heart Condition
HIV/AIDS
Does your child have any other medical conditions not listed above?
Yes
No
Please describe:
Which activities does the youth enjoy more?
Please select...
Indoor
Outdoor
Indoor or Outdoor
How would you describe the youth, in terms of participation in events, activities, or sports?
Please select...
No Preference
Watch, not Participate
Participate: Individual
Participate: Group
Participate: Individual or Group
Watch and Participate
I would like my child to feel empowered with the following:
Self-Awareness
- identifying emotions, ask for feedback, desire for self-improvement
Self-Management
- impulse control, stress management, self-motivation/discipline, organizational skills
Personal Responsibility
- remembering important information, handle belongings with care
Social Awareness
- empathy, respect for others, appreciating diversity
Relationship Skills
- communication, social engagement, relationship building, teamwork
Goal-Directed Behavior
- keep trying when unsuccessful, seek out additional information to achieve goals
Responsible Decision-Making
- identifying problems, accept responsibility for actions, learn from experiences
Optimistic Thinking
- attitude of confidence, hopefulness, say good things about themselves
Check all that apply
Why would you like your child to have a Big Brother/Big Sister?
What are your goals for your child this school year?
What does your child like to do in their free time?
Please list any preferences regarding your child's Big:
Please include any additional information that would be helpful for your child's Big to know:
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