Child Application

Do you have legal custody of the child?

Is there a person who shares legal custody of this child?

If yes, are they aware and supportive of the child's enrollment in the BBBS program?

*Phone Number

Child's First Name

Child's Middle Name

Child's Last Name

Suffix

Preferred Name/Nickname

Child's Date of Birth

Child's Gender

Personal Pronouns

Graduation Year

School Child Attends

Race/EthnicityAmerican Indian or Alaska NativeAsian - ChineseAsian - FilipinoAsian - IndianAsian - JapaneseAsian - KoreanAsian - VietnameseAsian - OtherBlack or African AmericanHispanic - Mexican, Mexican American, ChicanoHispanic - CubanHispanic - Puerto RicanHispanic - Other Latinx or Spanish originPacific Islander - ChamorroPacific Islander - Native HawaiianPacific Islander - SamoanPacific Islander - OtherWhite or CaucasianMiddle Eastern or North AfricanOtherPrefer Not To Say

Does the child have their own phone?

Does the child have their own email address?

National Origin: Is the child an immigrant/refugee?

Has the child ever been involved with the police or juvenile justice system?

Does the child have a parent/guardian who is currently incarcerated?

What is the child's living situation?

Relationship To Child

*Parent/Guardian First Name

*Parent/Guardian Last Name

Parent/Guardian Date of Birth

Preferred Phone

Best Time to Call

*Phone Number

Preffered Email

*Email Address

Contact Preference

Employer

Please Check OneI do consent to the use of identifying information and video, film and photographs in agency publications, promotional materials(including Facebook, Instagram & Twitter)I do not consent to the use of identifying information and video, film and photographs in agency publications and promotional materials(including Facebook, Instagram & Twitter)

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Is your mailing address is different from your residential address?YesNo

Annual Household Income

How many people are currently living in your household?

Is the child eligible to receive free/reduced lunch?

Does your family receive income assistance?

Do you anticipate any significant life changes over the next year, or have you had any in the past year?

Has your child had any involvement with your local children's service agency?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship To Child:

Is the child taking any medications?

Does the child have any allergies?

Child's Mental Health DiagnosesNoneAnxiety/PanicDepressionOppositional Defiance Disorder (ODD)SchizophreniaTourette SyndromeAgoraphobiaBipolar DisorderObsessive Compulsive Disorder (OCD)PTSDSuicidal IdeationOther

Child's Developmental DiagnosesNoneADHD/ADDAutismCerebral PalsyIntellectual DisabilityVisual ImpairmentAsperger’s SyndromeDyslexiaHearing ImpairmentLearning DisabilityTraumatic Brain InjuryOther

Child's Exposure to TraumaNoneBullyingDeath of a ParentDrug AddictionHomelessnessPhysical AbuseAlcohol AddictionCommunity ViolenceDomestic AbuseEmotional AbuseNeglectSexual AbuseOther

Chronic IllnessesNoneChronic or Acute AsthmaHeart ConditionCancerDiabetesHIV/AIDS

Development GoalsSelf-Awareness - identifying emotions, ask for feedback, desire for self-improvementPersonal Responsibility - remembering important information, handle belongings with careGoal-Directed Behavior - keep trying when unsuccessful, seek out additional information to achieve goalsOptimistic Thinking - attitude of confidence, hopefulness, say good things about themselvesSelf-Management - impulse control, stress management, self-motivation/discipline, organizational skillsSocial Awareness - empathy, respect for others, appreciating diversityRelationship Skills - communication, social engagement, relationship building, teamworkResponsible Decision-Making - identifying problems, accept responsibility for actions, learn from experiences

Does your child have any other medical conditions not listed above?YesNo

Which activities does the youth enjoy more?

How would you describe the youth, in terms of participation in events, activities, or sports?

Why would you like your child to have a Big Brother/Big Sister?

What are your goals for your child this school year?

What does your child like to do in their free time?

Please list any preferences regarding your child's Big

Please include any additional information that would be helpful for your child's Big to know

How did you hear about Big Brothers Big Sisters?

Consent for Youth Participation

Child Information

Parent/Guardian Information

Family Information

Emergency Contact

Additional Information

Day of Week	Start Time	Start Time AM/PM	Start/End Time Separator	End Time	End Time AM/PM
Monday	8:00	AM	-	4:00	PM
Tuesday	8:00	AM	-	4:00	PM
Wednesday	8:00	AM	-	4:00	PM
Thursday	8:00	AM	-	4:00	PM