Little Referral Form
Thank you for your interest in referring a Little to our program! Please complete the form below for us to begin outreach to the family to start their enrollment process. Please only complete one form per child.
Student first name
Student last name
Students gender
Please select...
Male
Female
Genderqueer or non-binary
Trans male
Trans female
School
Grade
School Account ID
What county is your school in?
Please select...
Carrol (Kentucky)
Greene (Indiana)
Jackson (Indiana)
Jefferson (Indiana)
Jennings (Indiana)
Lawrence (Indiana)
Monroe (Indiana)
Morgan (Indiana)
Owen (Indiana)
Scott (Indiana)
Switzerland (Indiana)
Trimble (Kentucky)
Counselor/Teacher first name
Counselor/Teacher last name
Counselor/teacher email
Parent/Guardian first name
Parent/Guardian last name
Parent/guardian email
Parent/guardian phone number
Is this student frequently tardy and/or absent?
Yes
No
Which areas are of concern for this student?
Social Skills
Academics/Study Skills
Behavior
Self-Esteem
Attendance
Does this student have an IEP or receive other services at school?
Yes
No
Please explain
How will this student benefit from being matched with a volunteer mentor?
Does this student have any behavior, emotional, or physical challenges that may pose a challenge to a volunteer?
Because most of our volunteer mentors are females, many boys can and will be matched with a Big Sister. When possible, a Little Brother will be matched with a Big Brother.
If this student is a Little Brother, is it okay for this Little to be matched with a Big Sister? Please explain:
Please share anything else that you think is important or helpful for our staff to know about this child and their family.
Is the family aware that you have made this referral?
Yes
No
Contact Information