ENROLL YOUR CHILD

Guardian Information

Guardian First Name

Guardian Last Name

Guardian Email

Guardian Mobile Phone

Guardian Street Address

City

State

Zip Code

Spanish preferred?

YesNo

What language(s) do you speak? Hold the control key down to select more than one option

What is your preferred language(s)? Hold the control key down to select more than one option

How did you hear about the program?

What is their counselor or therapist's full name?

Who told you about the program?

Which school does your child attend?

What's the name of the community organization?

Child's Information

Child's First Name

Child's Last Name

Your Relationship to Child

Child's Date of Birth

Child's Gender

FemaleMaleNon-BinaryPrefer to self-describe

Please share your child's race and select all that apply. Hold the control key down to select more than one option

BBBSEM is committed to being an anti-racist organization. We use racial indicator information to hold our agency accountable as we strive for greater equity.

How long has the child lived in the current home?

Do you expect the child to be moving in the next 12-18 months?

YesNo

How do you prefer we follow up with you?

Phone CallVideo CallEmail/TextInterpretation Needed for Deaf/Hard of Hearing

What is your comfort level with technology?

I am completely comfortable using apps, email, web forms, etc.I sometimes use apps and emails, but prefer to text or call.I feel most comfortable speaking on the phone.I feel most comfortable connecting via text message.Other (please share below)

Please share your comfort level with technology here.

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