CBBBS Youth Inquiry Form

Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. Participant eligibility shall be determined without regard to race, color, national origin, gender, religion, marital status, sexual orientation, gender identity, veteran status, or disability. 

Youth Information
Información de jóven

Enrollment Record ID

Contact Record ID

PG Contact Record ID

First Name

Nombre

Last Name

Apellido

Preferred First Name

Nombre Preferido

Birthdate

Fecha de Nacimiento

Gender

Please select... Male Female Trans Male Trans Female Genderqueer/Nonbinary Different Identity Prefer not to sayGénero 

How does the youth identify?

¿Cómo se identifica el jóven?

Personal Pronouns

Please select... He, Him She, Her They, Them Write InPronombres personales

What pronouns does the youth use?

¿Qué pronombres usa la juventud?

High School Graduation Year

Please select... 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 2050Año de graduación de la escuela secundaria

Race/Ethnicity (please click all that apply)
Etnicidad (por favor haga clic en todo lo que corresponda) 

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

I would like to enrol a second child

YesNo

Youth Information (#2)
Información de jóven

Enrollment Record ID

Contact Record ID

PG Contact Record ID

First Name

Nombre

Last Name

Apellido

Preferred First Name

Nombre Preferido

Birthdate

Fecha de Nacimiento

Gender

Please select... Male Female Trans Male Trans Female Genderqueer/Nonbinary Different Identity Prefer not to sayGénero 

How does the youth identify?

¿Cómo se identifica el jóven?

Personal Pronouns

Please select... He, Him She, Her They, Them Write InPronombres personales

What pronouns does the youth use?

¿Qué pronombres usa la juventud?

High School Graduation Year

Please select... 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 2050Año de graduación de la escuela secundaria

Race/Ethnicity (please click all that apply)
Etnicidad (por favor haga clic en todo lo que corresponda) 

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

I would like to enrol a third child

YesNo

Youth Information (#3)
Información de jóven

Enrollment Record ID

Contact Record ID

PG Contact Record ID

First Name

Nombre

Last Name

Apellido

Preferred First Name

Nombre Preferido

Birthdate

Fecha de Nacimiento

Gender

Please select... Male Female Trans Male Trans Female Genderqueer/Nonbinary Different Identity Prefer not to sayGénero 

How does the youth identify?

¿Cómo se identifica el jóven?

Personal Pronouns

Please select... He, Him She, Her They, Them Write InPronombres personales

What pronouns does the youth use?

¿Qué pronombres usa la juventud?

High School Graduation Year

Please select... 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 2050Año de graduación de la escuela secundaria

Race/Ethnicity (please click all that apply)
Etnicidad (por favor haga clic en todo lo que corresponda) 

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

Parent/Guardian (P/G) Information
Información de Padre/Guardián

P/G First Name

Nombre de P/G

P/G Last Name

Apellido de P/G

P/G'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 MgrRelación con el estudiante

Mobile Phone

Celular

Home Phone

Teléfono

Work Phone

Teléfono de Negocio

Preferred Phone

Please select... Mobile Home WorkTeléfono preferido

Best time to call

Please select... Anytime Daytime Evening WeekendEl mejor tiempo para llamar

Personal Email

Correo electrónico personal

I prefer to be contacted via:

Please select... Phone EmailContacto preferido

How did you hear about Catholic Big Brothers Big Sisters of LA?

Please select... BBBS Board/Staff College Partner Faith Organization Foster Home Fraternity/Sorority High School Partner Law Student Association Legal System Media Neighbor/Friend Other Big Relative School Self Service Organization Special Event Therapist/Counselor Web Link Workplace Partner/BusinessCómo se enteró acerca de Big Brothers Big Sisters?

Please list the specific NAME related to your answer above (e.g. school, social services agency, other Little, website, etc.)

Por favor, indique el NOMBRE específico relacionado con su respuesta anterior (por ejemplo, escuela, agencia de servicios sociales, otro Little, sitio web, etc.)

Please tell us briefly why you would like a mentor for your child:

¿Cuál es la razón principal de que querer a su hijo a tener un Big Brother o Big Sister?

Youth's Residential Address 
Dirección de jóven

Street Address (please include apartment or unit #)

Domicilio (por favor, incluya apartamento o unidad #)

City

Ciudad

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 WYEstado

Zip Code

Hidden Zip Code