Youth Application and Parent/Guardian Permission Form
Hidden Fields
Contact ID 18 Character
Enrollment ID 18 Character
Contact Owner ID
Contact Owner Email
Parent/Guardian Information
PG First Name
PG Last Name Name
Preferred Name
Gender Identity
Please select...
Female
Gender Fluid
Gender Queer
Gender Neutral
Male
Non-Binary
Trans Female
Trans Male
Personal Pronouns
Please select...
He/Him
She/Her
TheyThem
Ve/Ver
Xe/Xem
Relationship to Child
Please select...
Father
Mother
Foster Parent
Grandparent
Other Family
School Counselor
Step-Parent
Other
Please state your relationship
Do you have legal custody of the child?
Yes
No
Is there a person who shares custody of the child?
Yes
No
Name
Phone Number
Are they aware and supportive of participation in the BBBS Program?
Yes
No
Parent/Guardian Cell Phone
Is it Ok to Text the Parent/Guardian?
Yes
No
Parent/Guardian Place of Employment
Work Phone
May we contact you at work?
Yes
No
Email
Please check the time to contact you?
Morning
Afternoon
Evening
Emergency Contact
If we are unable to reach you, who is someone we could call who always knows how to reach you?
Name
Phone
Relationship to child/family
Please select...
Father
Mother
Foster Parent
Grandparent
Other Family
School Counselor
Step-Parent
Neighbor
Sibling
Child's Information
Child's Cell Phone
Is it Ok to Text the Child?
Yes
No
Home Phone
Child's First Name
Middle Name
Child's Last Name
Preferred Name
Gender Identity
Please select...
Female
Gender Fluid
Gender Queer
Gender Neutral
Male
Non-Binary
Trans Female
Trans Male
Personal Pronouns
Please select...
He/Him
She/Her
TheyThem
Ve/Ver
Xe/Xem
Birthdate
What is the child's living situation?
Please select...
Two-Parent Household
One-Parent Household
Grandparent
Foster Home
Group Home
Other Relative
Other
Who does child live with?
Home Address
City
State
Zip Code
Tribal Affiliations
Languages Spoken in the Home
Child's Race
American Indian
Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Multi-Race
Other
Child's Ethnicity
Hispanic
Non-Hispanic
Other Race:
School and Services
Child's School
Child's Grade
Within the last year, has your child been in trouble at school?
Poor Grades
Skipping School/Classes
Behavior Problems
Suspended
Expelled
Attending alternative school programs
Please provide more information regarding the identified concerns.
Has your child ever been arrested or involved in the juvenile justice system?
Yes
No
Please explain
Does your child receive any of these services?
504 Plan
ABA Therapy
Special Education
Speech Therapy
Tutoring
In-school Counseling
Other Counseling
WISE Program Services
What strengths does your child have that a Big might be able to encourage?
What are some of the needs your child have that a Big may be able to support?
Examples: social, emotional, academic
How would you describe the best Mentor for your child?
Participation Information
What is the primary reason for you wanting your child to have a Big Brother or 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.
Event
Faith Organization
Juvenile Justice System Referral
Relative
Service Organization (nonprofits, food bank, social services)
School
TV/Radio
Website
Other
Does your child have siblings or relatives applying for the BBBS program or currently in the program?
Yes
No
Please provide their names.
Do you anticipate any significant live changes in the next year or have had any life changes the past year?
Yes
No
Life changes include: moving, job changes, changes in family size or dynamics.
Please Explain
Will your child be able to meet with their Big on a regular basis for the next year?
Yes
No
Does your child have any medical conditions that might affect their participation in activities with their Big?
Yes
No
Please Explain
Household Information
How many adults and children reside in your house?
Please select...
1
2
3
4
5
6
7
8
9
10
Do you receive public income assistance?
Yes
No
Do you receive housing assistance?
Yes
No
Is your child eligible for Free/Reduced Lunch?
Yes
No
Does the child have a parent or guardian currently incarcerated?
Yes
No
Annual Household Income:
0-$10,000
$10,001 - $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
$50,000 - $54,999
$55,000 - $59,999
$60,000 - $74,999
$75,000 - $99,999
$100,000 - $124,999
$125,000 - $149,999
$150,000 - $199,999
$200,000 and up
Does your child have a parent/guardian with current of past military experience?
Yes
No
Dates of Service:
Branch of Service
Air Force
Army
Marine Corps
Navy
Coast Guard
Enlistment (check all that apply)
Active
National Guard
Reserves
Retired
Gold Star
Currently Deployed?
Yes
No
Deployment Dates:
Contact Information