Child Enrollment Application

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12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Hidden Fields

Youth Contact Owner ID

Youth Contact Owner Email

Youth Contact ID

Youth Enrollment ID

Guardian Contact ID

Additional Youth Found

YesNo

Click HERE to review our program guidelines before completing the application.

Child Information

Child's First Name

Child's Middle Name

Child's Last Name

Child's Preferred First Name

Mailing Street Address

Please include unit or apartment #

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Child's Date of Birth

Gender

Race/Ethnicity	How does the child identify?
School Please include full school name

School District

High School Graduation Year

This is the year the child will graduate high school.

Grade Level

Child's Primary Language

Child's Secondary Language

Is the child eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

Does the child have a parent/guardian who is currently incarcerated?

YesNo

Has the child ever been involved with the police or juvenile justice system?

What was their involvement?

What kind of custody do you have of your child?

Other

Please explain

Does the second Custodial Parent/Guardian live in the same home as the child?

NON-Custodial Parent

A NON-Custodial Parent is a parent who does NOT live in the home.

Name of NON-Custodial Parent

NON-Custodial Parent Date of Birth

Email of NON-Custodial Parent

Phone of NON-Custodial Parent

Home Address of NON-Custodial Parent

City

State

Zip Code

How often does your child have contact with the NON-Custodial Parent?

DailyWeeklyMonthlyYearlyHas never had contact with my child

Describe your child's relationship with the NON-Custodial Parent:

CloseDistantIndifferentNone

Does the NON-Custodial Parent have a court ordered visitation agreement?

YesNo

Have you notified the NON-Custodial Parent about enrolling your child in our program?

YesNo

Household Information

Annual Household Income

How many people are supported by this income?

Household Living Situation

Living Situation Description

Who lives in your home?
(Please include yourself, your children, other family members and non-family members)

Name

Relation to Child

Age

Primary Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Age

Parent/Guardian Date of Birth

Mobile Phone

Can we send texts to the mobile phone number provided above?

Yes, I agree to receive updates, reminders, and event opportunities text messages from Big Brothers Big Sisters. Agreeing to this isn't a condition of participation in the program. I agree to the Terms of Service and Privacy Policy. Approx. 4 Msgs/Month. Msg & data rates may apply.

Home Phone

Work Phone

Work Phone Extension

Preferred Phone

Best Time to Call

Does the child have their own phone?

YesNo

Child's Phone

Does the child have their own email?

YesNo

Child's Email

Parent/Guardian's Relationship to Child

Personal Email

Work Email

Preferred Email

Contact Preference

Primary Parent/Guardian's Employment Status

Employer

Occupation

Employer City

Employer State

Employer Zip Code

Parent/Guardian's Primary Language

Parent/Guardian's Secondary Language

Parent/Guardian's Relationship Status

Parent/Guardian's Military Status

Parent/Guardian's Level of Education

Is there a second parent/guardian who lives in the home?

YesNo

Is your family bilingual?

YesNo

What type of insurance do you have?

Secondary Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Age

Parent/Guardian Date of Birth

Mobile Phone

Home Phone

Work Phone

Work Phone Extension

Preferred Phone

Best Time to Call

Parent/Guardian's Relationship to Child

Personal Email

Work Email

Preferred Email

Contact Preference

Secondary Parent/Guardian's Employment Status

Employer

Occupation

Employer City

Employer State

Employer Zip Code

Parent/Guardian's Primary Language

Parent/Guardian's Secondary Language

Parent/Guardian's Relationship Status

Parent/Guardian's Military Status

Parent/Guardian's Level of Education

Emergency Contact

Someone other than the Parent/Guardian

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Home Address

Emergency Contact City

Emergency Contact State

Emergency Contact Zip Code

Emergency Contact Relationship to Child

Health Information

Name of Your Child's Doctor

Type NA if none

Phone Number of Doctor's Office

Type NA if none

Family Insurance Provider

Type NA if none

Is your child taking any medications?

YesNo

Medications Description

(ex. EpiPen, Inhaler)

Please mark boxes to indicate if your child has any of the following health conditions:

AsthmaAllergiesDiabetesSeizuresOther

Allergies Description

(ex. Peanuts, bees, penicillin)

Other

Please explain

Explain any other health problems your child may have (please include mental health and learning disabilities):

Referral Information

Has your child had contact with any of the following professionals within the last TWO years? (Mark all that apply)

School Psychologist/Counselor	WRAPAROUND Service
Private Therapist	Probation Officer
Police/Sheriff	Academic Counselor/Tutor
Social Worker	G.R.I.P.
None

Please provide their contact information below:

Professional's Full Name

Professional's Titile

Name of Organization

Organization's Address

Organization's Phone Number

Organization's Fax Number

How long has your child been an active member of their service?

How did you hear about Big Brothers Big Sisters?

Referral Detail ID

If you selected Legal System, Service Organization or Other, please provide the name of the organization/agency here.

Technology and Connectivity

Do you have a computer or tablet?

YesNo

Does your child have their own computer or tablet?

YesNo

Do you have a reliable internet connection at home?

YesNo

Is it a personal device or issued by a school?

PersonalSchool

Child Schedule, Availability & Hobbies

Is your child involved in Extracurricular Activities at school or in the community?

YesNoFor example: Boys & Girls Club, YMCA, YWCA, sports, Explorers, Cadets, Boy Scouts, Girl Scouts, or church activities

What activities are they involved in?

Check off the days when your child's schedule includes school, sports, extracurricular activities, and other regular commitments.

Monday AM	Monday Afternoon	Monday PM
Tuesday AM	Tuesday Afternoon	Tuesday PM
Wednesday AM	Wednesday Afternoon	Wednesday PM
Thursday AM	Thursday Afternoon	Thursday PM
Friday AM	Friday Afternoon	Friday PM
Saturday AM	Saturday Afternoon	Saturday PM
Sunday AM	Sunday Afternoon	Sunday PM

What are your child's additional hobbies & interests?

Type NA if none

Consent & Agreement Form

Please initial each item and complete form with your signature and date.

1. I understand that my child and I will need to participate in separate interviews. I further understand that the interviews conducted will require a detailed family history that will determine if the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) program is appropriate for my child’s needs.

Initials

2. I understand that all information provided by myself will be considered confidential within the agency’s limits of the law. However, California law does require that all professionals who work with families and children under the age of 18 report known and suspected incidents of child abuse, as well as threats of harm to oneself or others.

Initials

3. I, the undersigned, understand that all information I disclose to BBBSOC/IE, whether disclosed in my Enrollment Form, questionnaires, interviews or otherwise, and whether in writing or orally, may be disclosed to the volunteer of a prospective or matched Little Brother/Little Sister and I hereby consent to such disclosure.

Initials

4. I, the undersigned, understand that BBBSOC/IE may be subpoenaed or otherwise ordered to produce the information included in this application and/or information collected by the agency during program participation. I hereby authorize BBBSOC/IE to release such information pursuant to any such subpoena or other order and further agree to release and hold BBBSOC/IE harmless for any and all claims arising from BBBSOC/IE 'release of said information.

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5. I understand that all information obtained through the application process is the sole property BBBSOC/IE. I understand that I relinquish my rights to have access to this information.

Initials

6. I understand that before my child can be accepted, we must attend a workshop discussing the topic of child sexual abuse prevention.

Initials

7. I understand that after my child is accepted into the program, the staff will try to match him/her with a volunteer mutually agreed upon by myself and the agency. However, BBBSOC/IE does not guarantee that my child will be matched.

Initials

8. I understand that the information obtained during the interview process will be shared with prospective volunteers, as a means to familiarize them with my child.

Initials

9. I declare that the non-custodial parent will not be a concern to a volunteer matched to my child, nor to their relationship. If I find out that the situation and/or circumstances change, I will notify the agency, as well as the volunteer.

Initials

10. I understand that if my child is not accepted into the program, I will not be provided with an explanation.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Media Consent and Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”). I hereby accept the invitation of Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) for My Child to appear and be identified in print or online in any BBBSOC/IE publication or production. I hereby grant BBBBSOC/IE and its affiliates the absolute right and permission to use the image, name, and biographical information of My Child as BBBBSOC/IE may desire, in all media and in all forms whatsoever, including, but not limited to: magazines, brochures, press releases, print publications; motion pictures, television, cablecast and satellite broadcasts; the internet and mobile applications. Examples include, but are not limited to, the Orange County Register and other print news media, televised news media, promotional print media, and the BBBSOC/IE website and social media channels. In consideration of $0 to be paid to me, I hereby grant to BBBSOC/IE and its affiliates the absolute right to use images made through BBBSOC/IE studios or elsewhere, in whole or in part, in true or distorted character or form, alone or in conjunction with any other image, name or reproduction, in color or otherwise, for art, advertising, promotion, business, trade, or any other lawful purpose whatsoever, in perpetuum. I hereby waive any right that I may have to inspect and/or approve of the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied.

I hereby release BBBSOC/IE and its affiliates from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSOC/IE ’s exercise of the right hereby granted. These include, without limitation, claims for compensation, claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory. BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Initials

2. I do not grant Big Brothers Big Sisters of Orange County/Inland Empire the right to use the image of the minor child specified below.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relation to Minor Participant

Communication Consent & Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”), who is participating in the Traditional Program (the “Program”) offered by Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) as a child mentee, or “Little”. I hereby consent and give My Child permission to communicate virtually and/or electronically with My Child’s Big or mentor. Such communication may include, without limitation, telephone, text message, email, and video conferencing programs such as Zoom, CommandLink, Google Classroom, and FaceTime. Such communication may also include social media platforms including, without limitation, Instagram, Facebook, Twitter, and TikTok, and online video game platforms including, without limitation, Xbox Live, Nintendo Switch Online, and PlayStation Plus.

I WILL COMMUNICATE WITH MY CHILD, WITH MY CHILD’S BIG OR MENTOR, AND WITH BBBSOC/IE TO DETERMINE WHICH COMMUNICATION METHODS AND PLATFORMS I APPROVE.

I further agree to supervise, monitor, and otherwise stay informed about My Child’s virtual and/or electronic communication with My Child’s Big or mentor, and to maintain an open dialogue with My Child concerning these virtual and electronic interactions.

I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, volunteers, agents, affiliates, successors, and assigns, arising out of or attributable to My Child’s virtual and/or electronic communication with My Child’s Big or mentor, and other Littles or mentees participating in the Program.

BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Initials

2. I do not consent or give My Child permission to communicate virtually and/or electronically with My Child’s Big or mentor, or other Littles or mentees participating in the program.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relation to Minor Participant

RELEASE AND WAIVER OF LIABILITY

I, the undersigned, am the parent and/or legal guardian of ___type name below___ , a minor (“My Child”), and I agree to permit him/her to attend and participate in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) Traditional Program (the “Program”).

I understand that certain risks and dangers may exist in My Child’s attendance and participation in the Program, and such attendance and participation is conditioned upon my agreement to release BBBSOC/IE from any claims of liability, including, but not limited to, any claims for property loss or personal injury to My Child. Therefore, in exchange for the opportunity of My Child to attend and participate in the Program, I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, agents, affiliates, successors, and assigns (collectively, “Releasees”), on account of injury, death, property damage, or economic loss arising out of or attributable to My Child’s participation in the Program, including, without limitation, to travel to or from their school/site or field trip/program destinations, whether arising out of the ordinary negligence of BBBSOC/IE or any Releasees or otherwise. I covenant not to make or bring any such claim against BBBSOC/IE or any other Releasee, and forever release and discharge BBBSOC/IE and all other Releasees from liability under such claims. This waiver and release does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that California law does not permit to be released by agreement.I understand that by signing this agreement, I am waiving for My Child any and all claims, of any kind arising out of or attributable to My Child’s participation in the Program, including those claims that may be unknown to me, or which I do not suspect to exist at this time.

WITH THE INTENTION OF WAIVING ALL UNKNOWN AND UNSUSPECTED CLAIMS, I HEREBY EXPRESSLY WAIVE ALL RIGHTS, BENEFITS, AND PROTECTIONS I MAY HAVE UNDER CALIFORNIA CIVIL CODE SECTION 1542, WHICH READS AS FOLLOWS:

“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.”

I shall defend, indemnify, and hold harmless BBBSOC/IE and all other Releasees against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys’ fees, fees and the costs of enforcing any right to indemnification under this agreement, and the cost of pursuing any insurance providers arising out of or resulting from any claim of a third party related to My Child’s participation in the Program, including any claims arising out of my own negligence, the negligence of My Child, or the ordinary negligence of BBBSOC/IE.

THIS AGREEMENT PROVIDES BBBSOC/IE WITH MY ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE BBBSOC/IE FOR ANY CLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relation to Minor Participant

ATTENTION: Anaheim Residents Only

Please note that if your current mailing city is Anaheim, you will be redirected to the Anaheim CDBG supplemental form after clicking "Submit" below.

More information will be provided there.

Thank you in advance for completing all required documentation!

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