Parent/Guardian First Name:
Parent/Guardian Last Name:
Prefer not to say
Prefer not to say
Parent/Guardian Date of Birth:
Relationship to child:
Parent/Guardian Relationship Status
Home Address Line 1
Home Address Line 2
District Of Columbia
Northern Mariana Islands
Parent/Guardian Home or Cell Phone #
Is it okay to text parent/guardian?
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?
Is there another person who shares legal custody of this child with you?
Are they aware of the child's enrollment in the BBBS program?
Name of Person with Shared Custody
Phone # of Individual with Shared Custody
Child's First Name:
Child's Last Name:
Prefer not to say
Prefer not to say
Child's Date of Birth:
American Indian or Alaska Native
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
Hold Ctrl To Select Multiple
Nationality/Country of Origin:
Have you discussed our program with your child?
Do they seem interested in participating?
Do you think they will want to participate once you discuss it with them?
What is the primary reason you want your child to have a Big Brother/Big Sister?
Does your child have any medical conditions (physical or mental) that might affect their participation in activities with a Big?
Please describe any physical or mental health challenges:
Do you believe your child has experienced any traumatic events?
If you are able, please describe any traumatic events your child may have experienced:
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.
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:
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:
$200,000 or more
Are you receiving income assistance at this time?
Are you receiving assistance with housing (e.g. Section 8, residence in public housing, etc.):
If living in a housing development, please list the name:
Is child eligible for free or reduced lunch?
Yes - Free
Yes - Reduced
Has your family moved within the last 12 months:
Child is being raised by:
Two Parent: Not Married
One Parent: Female
One Parent: Male
Other child-rearing arrangement:
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.