Parent/Guardian/Little Application
Parent/Guardian Information
Parent/Guardian First Name:
Parent/Guardian Last Name:
Parent/Guardian Gender:
Please select...
Female
Male
Trans
Nonbinary
Genderqueer
Genderfluid
Other
Prefer not to say
Pronouns:
Please select...
She/Her
She/They
He/Him
He/They
They/Them
Nonouns
Prefer not to say
Parent/Guardian Date of Birth:
Relationship to child:
Parent/Guardian Relationship Status
Please select...
Married
Single
Domestic Partner
Other
Home Address Line 1
Home 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
Parent/Guardian Home or Cell Phone #
Is it okay to text parent/guardian?
Yes
No
Parent/Guardian Email
Parent/Guardian Place of Employment:
Parent Work Phone #
Optional - We will only call this number if necessary.
Legal Guardianship Information
Do you have legal custody of the child?
Yes
No
Is there another person who shares legal custody of this child with you?
Yes
No
Are they aware of the child's enrollment in the BBBS program?
Yes
No
Name of Person with Shared Custody
Phone # of Individual with Shared Custody
Youth Information
Youth Demographics
Child's First Name:
Child's Last Name:
Child's Gender
Please select...
Female
Male
Trans
Nonbinary
Genderqueer
Genderfluid
Other
Prefer not to say
Child's Pronouns:
Please select...
She/Her
She/They
He/Him
He/They
They/Them
Nonouns
Prefer not to say
Preferred/Chosen/Nick Name:
Child's Date of Birth:
Child's School:
Grade:
Child's Race/Ethnicity
Please select...
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other
Hold Ctrl To Select Multiple
Nationality/Country of Origin:
Youth Knowledge/Interest
Have you discussed our program with your child?
Yes
No
Do they seem interested in participating?
Yes
No
Do you think they will want to participate once you discuss it with them?
Yes
No
What is the primary reason you want your child to have a Big Brother/Big Sister?
Youth Health
Does your child have any medical conditions (physical or mental) that might affect their participation in activities with a Big?
Yes
No
Please describe any physical or mental health challenges:
Do you believe your child has experienced any traumatic events?
Yes
No
Unsure
If you are able, please describe any traumatic events your child may have experienced:
Media Release
Would you allow your child to appear in or be featured in any of the following promotional activities for BBBS? printed promotional material, social media uses.
Television Ads
News Stories
Printed Promotional Materials (flyers, recruiting materials, etc)
Social Media Posts
None - I do not wish for my child to appear in any of the above items.
Parent Preferences for Match
Big Brothers Big Sisters of the Tri-State does not discriminate on the basis of race, age, sex, gender identity or expression, disability, marital status, sexual orientation, religion, or national origin. We will always honor your preferences, but please note that the more restrictions you place on a Big, the longer it may take to match your child.
Please tell us if you have preferences for a Big who identifies with the following items (write "No preference" or something similar if you have no preferences):
Preferences surrounding race/ethnicity:
Preferences surrounding religion/faith:
Preferences surrounding romantic/sexual orientation:
Preferences surrounding gender identity and expression:
What age range would you prefer for your child's Big?
Emergency Contact Information
If there is an emergency and we can't get in contact with you, who would you prefer us to call instead?
Emergency Contact Name:
Relationship to you:
Phone #
Family/Household Information
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 the children in our communities.
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
Are you receiving income assistance at this time?
Yes
No
Are you 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
Child is being raised by:
Please select...
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
Other child-rearing arrangement:
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.
Click the button below to review your application, and then sign at the bottom.
Contact Information