SB Youth Application and Permission

Child/Family/School Information

Parent/Guardian First Name

Parent/Guardian Last Name

What is your relationship to this Child?

Other Relationship

Child's Date of Birth

Child's First Name

Child's Last Name

Gender

How would you define yourself in terms of gender?

Racial Indicator

Other Race

Tribal Affiliation

Child's HS Graduation Year (click here to accurately calculate grad year)

Child's Current Grade Level

(2023-2024)

Child's School

School

Teacher Name

Street Address

City

State

Zip

County of Residence

Mobile Phone

Secondary Phone

Preferred Contact Method

Emergency Contact Information

Emergency Contact Full Name

Emergency Contact Relationship to Child

Emergency Contact Phone Number

Personal Information

Who lives in the home with your child? Please list names and ages

Was your child eligible to receive Free/Reduced Lunch in the 2022-23 school year?

For state and federal funding, we are asked to identify any children we serve who have a close family member who is currently incarcerated at any level or was recently released from local, county, state, or federal supervision. Does your child have a close family member who is incarcerated?

Is this a topic BBBS staff or a Big could talk to your child about if relevant?

Military Families: Does your child have a parent in the military?

Further Information

Building a strong relationship with a caring adult is the #1 goal in mentoring. Above and beyond that, please choose 1-2 items you would like to see this child explore through activities and/or reflection with his/her mentor. **To choose more than one item in a list, hold your Control OR Command key, depending on your keyboard.

Learning and Life Skills

Other Learning and Life Skills

Health and Wellness

Other Health and Wellness

Community and Leadership

Other Community and Leadership

Is there anything else we should know, when finding a Big Brother or Big Sister for your child?

Please list any allergies, health considerations, or current medications your child has and how they affect your child's participation in the program:

During the course of your child's participation in the program, he/she may be matched with more than one mentor. Please check one of the following regarding the validity of this form:

Are you planning any upcoming moves or school changes?

If yes, please explain

Preferences

Please state any preferences in terms of Race/Ethnicity, Religion/Faith or Sexual Orientation regarding the Big Brother or Big Sister who may be matched with your child.

Any other preferences in the characteristics of the volunteer

Note: BBBS does not discriminate on the basis of the above factors when screening potential volunteers. However, we will honor your preferences to the best of our knowledge.

Consent & Permissions

I hereby give my permission for BBBS to use identifying information (first name, photograph, match profile information) regarding my child now, and in the future, for agency publications, media productions, promotional materials, and online social networking media (Facebook, Twitter, blogs, etc.)

I give permission for my child to participate in the Big Brothers Big Sisters program. I understand that the BBBS agency is not obligated to match my child with a volunteer and that as part of the enrollment process my child and I will be asked to provide additional personal information. If my child is matched with a Big Brother or Sister, I agree to support my child’s match and to immediately report any concerns I might have to the Big Brothers Big Sisters staff.

Please include your signature below:

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Contact Information