GUARDIAN APPLICATION
Parent/Guardian Name(s):
Pronouns:
Parent/Guardian(s) Date of Birth:
Relationship to child:
Parent/Guardian Relationship Status
Married
Single
Domestic Partner
Other
Parent/Guardians Home Phone #
Parent/Guardian Cell Phone #
Parent/Guardians Email
Address Line 1
Address Line 2
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Do you have legal custody of the child?
Yes
No
Is there a person who shares legal custody of this child?
Yes
No
If yes, are they aware and supportive of the child's enrollment in the BBBS program?
Yes
No
Name of Person with Shared Custody
Phone # of Individual with Shared Custody
Child's First Name:
Child's Middle Name:
Child's Last Name:
Child's Pronouns:
Preferred Name/Nickname:
Child's Gender
Child's Date of Birth:
Child's Cell Phone # (if applicable)
Is it okay to text parent?
Yes
No
Is it okay to text child?
Yes
No
N/A
Child's email (if applicable)
Child's School:
Grade:
Child's Teacher:
Child's Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other
Multi- Race (check all that apply)
Nationality/Country of Origin:
Parent Place of Employment:
Parent Work Phone #
May we contact you (the parent/guardian) at the work number listed above?
Yes
No
Please check the best number to contact you (the parent/guardian)
Home
Cell
Work
Please check the best time to contact you (the parent/guardian)
Morning
Afternoon
Evening
If we are unable to reach you, who is someone we could call who always knows how to reach you?
Phone #
What is the primary reason for you wanting your child to have a Big Brother of Big Sister?
Does your child know that you are applying for the program?
Yes
No
Does your child want to participate?
Yes
No
Where did you hear about Big Brothers Big Sisters? Please check all that apply and provide details in space given.
TV/Radio
Website
Event
Relative
School
Friend/Neighbor
Youth Serving Organization (e.g. Boys and Girls Club)
Professional (e.g. Counselor, Social Worker)
Other
Please provide details below:
Do you anticipate any significant life changes over the next year or have you had any in the past year (e.g. moving, child changing schools, etc.)?
Yes
No
Does your child have any medical conditions (physical, mental) that might affect him or her participating in activities with a Big? If yes, please explain:
Has your child been traumatized by a recent event? If yes, please explain:
Would you allow your child to appear in or be featured in the following: Television ads/news stories, printed promotional material, social media uses.
Yes
No
Parent/Guardian Preferences:
Big Brothers Big Sisters of the Tri-State does not discriminate against race, age, sex, gender identity or expression, disability, marital status, sexual orientation, religion or national origin. While we honor your preferences, please note that the more restrictions you place on a Big, the longer it may take to match your child.
Do you have any concerns or preferences regarding your child's potential Big Brother or Big Sister in terms of the following:
Race
Yes
No
Religion/Faith
Yes
No
Age
Yes
No
Sexual Orientation
Yes
No
Gender Identity
Yes
No
If yes, please explain:
Parents of boys:
do you mind if your child has a Big Sister if a Big Brother is not available:
Yes
No
Additional Questions:
How would you describe the best mentor for your child?
What strengths does your child have that a Big might be able to help grow?
What are some of the needs your child has (could be social, emotional, behavior, or academic) that a Big may be able to help him/her with?
Are there other ways you think a Big Brother or Big Sister can support your child?
Is there anything else we need to know before matching your child with a Big?
Parent/Guardian Permission
I agree to the following:
1. I give permission for my child to participate in the Big Brothers Big Sisters Community, School Based, School Based Plus or Workplace Plus program.
2. I give permission for an agency representative to obtain additional information that may be helpful to the agency’s matching process, this may include information from the school/school board, other social service agencies or counseling references.
3. I understand that information about my child will be shared with a potential Big Brother/Sister and that my child and I will not be identified to a potential Big Brother/Sister until all parties have agreed to the match proposal.
4. I understand that information shared with me about a potential Big Brother or Big Sister will be confidential and I will not discuss such information with anyone other than the Big Brothers Big Sister staff.
5. I agree that a member of the Big Brothers Big Sisters staff will discuss safety with my child and will conduct an age appropriate safety training with them.
6. I acknowledge that the Big Brothers Big Sisters staff is required to report any known or suspected abuse or neglect of my child or occurring within my home.
7. I understand that even if my child is selected to be a part of the Big Brothers Big Sister program that he/she may have to wait for a volunteer mentor and it is additionally not guaranteed that my child will ever receive a Big Brother or Big Sister.
8. I understand that my child’s mentor will have gone through the Big Brothers Big Sisters screening necessary for the program they are applying for which includes at a minimum an in-depth interview, reference checks, and background checks.
9. I understand that when my child is matched to a Big Brother or Big Sister that we all (Big, parent, and child) will be required to do mandatory match support/supervision in order to maintain a healthy, safe and effective match relationship. I understand that a failure to adhere to this supervision schedule can result in the closure of my child’s match.
Type Name Below to sign:
Next steps, if you are applying for Community Based matching for your child, upon receiving this application in our office, we will call you and set up a time to come and interview you and your child at your home. If you are applying for School Based matching for your child, when you return this application to the school, the school personnel will notify us, and we will go to the school to interview you child. We will likely be calling you to answer any questions you may have and give you some information on child safety.
Client Statistics
Parents/Guardians: Please note that this information is confidential and is used only to help us secure funding that will help us continue to serve children.
Select Average Income of the home:
Please select...
Under $10,000
$10,000-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
$30,000-$34,999
$35,000-$39,999
$40,000-$44,999
$45,000-$49,999
$50,000-$59,999
$60,000-$74,999
$75,000-$99,999
$100,000-$124,999
$125,000-$149,999
$150,000-$199,999
$200,000 or more
Is the parent/guardian receiving income assistance at this time?
Yes
No
Is parent/guardian receiving assistance with housing (e.g. Section 8, residence in public housing, etc.):
Yes
No
If living in a housing development, please list the name:
Is child eligible for free or reduced lunch?
Yes - Free
Yes - Reduced
No
Has your family moved within the last 12 months:
Yes
No
Has the child been arrested or involved in the Juvenile Justice System:
Yes
No
Within the last year, has your child been in any trouble at school?
Yes
No
Other
If yes, what for?
Poor Grades
Skipping school/classes
Truant
Behavior Problems
Has been suspended
has been expelled
Sent to an alternative school
Does your child receive any services?
Speech Therapy
In-School Counseling
Counseling (Outside of School)
Education Support (e.g. IEP)
Other
If other, please explain:
Number of people (adults and children) in the household:
Is the child being raised by:
Two Parent
Two Parent: Not Married
One Parent: Female
One Parent: Male
Other Relative
Group Home
Foster Home
Institution
Grandparents
Sibling Guardian
Two Mothers
Two Fathers
Other
If other, please explain:
If child does not live with one or both parents, is the absent parent(s):
Incarcerated
Deceased
Deployed
Just not involved
Cannot see due to protective orders
Other
If Other, please explain:
If child does not live with one or both parents, do they see the absent parent(s):
Yes
Yes, but not regularly
No
Does your child have a guardian with current or past military experience?
Yes
No
If yes, please list dates of service:
Is the guardian currently deployed?
Yes
No
If yes, the date of deployment:
Is it possible the guardian will be deployed in the future?
Yes
No
Branch:
Air Force
Army
Marine Corps
Navy
Coast Guard
Component:
Active
National Guard
Reserve
Is the guardian retired from the military?
Yes
No
Is the guardian separated/discharged (other than retired)?
Yes
No
Does your child have a guardian that's considered fallen, wounded or disabled?
Yes
No
Does your child have a guardian who is currently incarcerated?
Yes
No
Has your child been exposed to substance misuse (e.g. alcohol, drugs)?
(This can be exposure due to misuse in the neighborhood and/or someone significant to the child)
Yes
No
Thank you for filling out the BBBS Guardian Application! A member of our enrollment staff will be in touch soon. We look forward to working with you and your child! If you have any questions please give us a call at (304) 522-2191.
Contact Information