KSBBBS Youth Referral

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.

Your Information

Your First Name

Your Last Name

Mobile Phone

NO - and NO ()! Numbers only

I prefer to be contacted by

What is your relationship to the child/youth being referred?

How did you hear about BBBS?

Youth Information

First Name

Last Name

Preferred Name

25 characters max

Birthdate (If Known)

Youth's Age

(Estimate if you aren't sure)

Application Name

Concatenated from First + Last

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?

School

School Account ID

Race/Ethnicity

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
Other	Pacific Islander - Chamorro
Pacific Islander - Native Hawaiian	Pacific Islander - Other
Pacific Islander - Samoan	Prefer not to say
White or Caucasian

Select as many as apply

Family Information (Please enter as much as is known)

Which location is nearest to the youth's residence?

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian's Relationship to Youth

Street Address

City

State

Zip Code

County

Parent/Guardian Email

Parent/Guardian Mobile Phone

Referral Information

Have you notified the youth's parent/guardian that you are making this referral?

YesNoOther

Please explain:

Has the youth being referred ever been matched in a Big Brothers Big Sisters program before?

YesNoI don't know

Does the youth being referred have any siblings currently matched in a Big Brothers Big Sisters program?

YesNoI don't know

If yes, please provide names of siblings:

Please provide your reason for referral or any other information or comments that you would like to share with the Big Brothers Big Sisters staff or that you think is important regarding this referral (Optional):

Contact Information