CHILD APPLICATION All information on this application is confidential. We use this information to assist in matching your child and for grant funding only. Step 1 of 3 33% Child Information(Required) First Name Middle Name Last Name Suffix e.g. Jr, IIIPreferred Name Birthdate MM slash DD slash YYYY Enter a date in the following format: mm/dd/yyyyGenderPlease select....MaleFemaleTrans MaleTrans FemaleGenderqueer/NonbinaryDifferent IdentityPrefer not to sayPersonal PronounsPlease select....He, HimShe, HerThey, ThemOther PronounGraduation Year2020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050School Child Attends Race/Ethnicity American Indian or Alaska Native Asian - Chinese Asian - Filipino Asian - Indian Asian - Japanese Asian - Korean Asian - Other Asian - Vietnamese Black or African American Hispanic - Cuban Hispanic - Mexican, Mexican American, Chicano Hispanic - Other Latinx or Spanish origin Hispanic - Puerto Rican Middle Eastern or North African Pacific Islander - Chamorro Pacific Islander - Native Hawaiian Pacific Islander - Other Pacific Islander - Samoan White or Caucasian Other Prefer not to say Does the child have their own phone? Yes No Does the child have their own email address? Yes No National Origin: Is the child an immigrant/refugee? Yes No Has the child ever been involved with the police or juvenile justice system? Yes No Does the child have a parent/guardian who is currently incarcerated? Yes No Child Living SituationTwo ParentOne Parent: FemaleOne Parent: MaleOther RelativeGroup HomeFoster HomeInstitutionGrandparentsSibling GuardianTwo Parent: Not MarriedTwo MothersTwo FathersOther/UnknownDoes the child have a parent/guardian who is serving or served in the military?NoYes: ActiveYes: Gold StarYes: ReservesYes: Retired/VetGuardian InformationGuardian's Relationship to YouthMotherFatherStep-MotherStep-FatherGrandmotherGrandfatherAuntUncleRelative: OtherFoster ParentTeacherCounselorClergyProbation OfficerNon-Relative: OtherSelf-Emancipated MinorSocial Worker-Case Mgr Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Birthdate: MM slash DD slash YYYY Input format: mm/dd/yyyyPreferred Phone(Required)Please Select...HomeWorkMobileOtherBest Time to CallAnytimeDaytimeEveningWeekendHome phone(Required) Work Phone(Required) HiddenPost Custom Field Mobile Phone(Required) Other(Required) Preffered Email(Required)Please Select...Personal EmailWork EmailAlternate EmailPersonal Email(Required) Work Email(Required) Alternate Email(Required) HiddenPost Custom Field Contact PreferencePhoneEmailText/SMSEmployer Type NA if unemployedIs there a person who shares custody of this child? Yes No How did you hear about us? Please Check One I 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)By signing below, I give permission: For my child to participate in the Big Brothers Big Sisters Program; For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to transport my child to events and match activities; For the school toprovide social and academicinformationabout my childtoBig Brothers Big Sisters (e.g. report cards, behaviorreports); To have my child participate in an in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests; To have my child talk with a Big Brothers Big Sisters staff person about personal safety; For BBBS staff to provide contact information for me and my child to the volunteer. I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I will be asked to provide additional information through an in-person interview. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information relevant to child-safety and well-being). I certify that all of the information on this form is true and correct and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject metoprosecution under applicable state andfederallaws.I understand this information will not affect my qualification for the program. I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me ashis/her guardian. I understand that this information maybe shared with the school or with partnership agencies when applicable. If my child is matched with a Big Brother or Big Sistem I agree to support my child’s match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff as outlined in expectations (which includes communication atleast once a month in the first year of the match), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.Parent/Guardian Signature:Date MM slash DD slash YYYY Family InformationMailing Street Address Mailing City Mailing StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMailing Zip Code Mailing CountryAdamsAllenAshlandAshtabulaAthensAuglaizeBelmontBrownButlerCarrollChampaignClarkClermontClintonColumbianaCoshoctonCrawfordCuyahogaDarkeDefianceDelawareErieFairfieldFayetteFranklinFultonGalliaGeaugaGreeneGuernseyHamiltonHancockHardinHarrisonHenryHighlandHockingHolmesHuron JacksonJeffersonKnoxLakeLawrenceLickingLoganLoganLucasMadisonMahoningMahoningMedinaMeigsMercerMiamiMonroeMontgomeryMorganMorrowMuskingumNobleOttawaPauldingPerryPickawayPikePortagePreblePutnamRichlandRossSanduskySciotoSenecaShelbyStarkSummitTrumbullTuscarawasUnionVan WertVintonWarrenWashingtonWayneWilliamsWoodWyandotPlease check here if your mailing address is different from your residential address Please check here if your mailing address is different from your residential address Annual Household IncomeLess than $10,000$10,000 to $14.999$15,000 to $19,999$20,000 to $24,999$25,000 to $29,999$30,000 to $34,999$35,000 to $39,999$40,000 to $44,999$45,000 to $49,999$50,000 to $59,999$60,000 to $74,999$75,000 to $99,999$100,000 to $124,999$125,000 to $149,999$150,000 to $199,999$200,000 or moreUnknownHow many people are currently living in your household? Is the child eligible to receive free/reduced lunch? Yes No Does your family receive income assistance? Yes No Do you anticipate any significant life changes over the next year, or have you had any in the past year? Yes No Has your child had any involvement with your local children's service agency? Yes No Emergency ContactIn the event you cannot be reached please provide an emergency contact:Name Emergency Contact First Name Emergency Contact Last Name Emergency Contact PhoneEmergency Contact Relationship to YouthAuntBrotherClergyCounselorCousinFamilyFatherFoster FatherFoster MotherFoster ParentFriendGrandfatherGrandmotherGrandparentMotherNeighborNon-Relative: OtherParentProbation OfficerRelative: OtherSiblingSisterSocial Worker-Case MgrStep-FatherStep-MotherStep-ParentTeacherUncleAdd another emergency contact Add another emergency contact Name Emergency Contact First Name Emergency Contact Last Name Emergency Contact PhoneEmergency Contact Relationship to YouthAuntBrotherClergyCounselorCousinFamilyFatherFoster FatherFoster MotherFoster ParentFriendGrandfatherGrandmotherGrandparentMotherNeighborNon-Relative: OtherParentProbation OfficerRelative: OtherSiblingSisterSocial Worker-Case MgrStep-FatherStep-MotherStep-ParentTeacherUncleThe following information will help assist us in matching your child to a screened Big (volunteer).Is the child taking any medications? Yes No Does the child have any allergies? Yes No Child's Mental Health Diagnoses: None Anxiety/Panic Depression Oppositional Defiance Disorder (ODD) Schizophrenia Tourette Syndrome Agoraphobia Bipolar Disorder Obsessive Compulsive Disorder (OCD) PTSD Suicidal Ideation Other Check all that applyChild's Developmental Diagnoses: None ADHD Autism Cerebral Palsy Intellectual Disability Memory Loss Visual Impairment ADD Asperger’s Syndrome Dyslexia Hearing Impairment Learning Disability Traumatic Brain Injury Other Check all that applyChild's Exposure to Trauma: None Bullying Death of a Parent Drug Addiction Homelessness Physical Abuse Alcohol Addiction Community Violence Domestic Abuse Emotional Abuse Neglect Sexual Abuse Other Check all that applyChronic Illnesses: None Chronic or Acute Asthma Heart Condition Cancer Diabetes HIV/AIDS Check all that applyDoes your child have any other medical conditions not listed above? Yes No Which activities does the youth enjoy more?IndoorOutdoorIndoor or OutdoorHow would you describe the youth, in terms of participation in events, activities, or sports?No PreferenceWatch, not ParticipateParticipate: IndividualParticipate: GroupParticipate: Individual or GroupWatch and ParticipateChronic Illnesses: Self-Awareness - identifying emotions, ask for feedback, desire for self-improvement Self-Management - impulse control, stress management, self-motivation/discipline, organizational skills Personal Responsibility - remembering important information, handle belongings with care Social Awareness - empathy, respect for others, appreciating diversityRelationship Skills - communication, social engagement, relationship building, teamwork Goal-Directed Behavior - keep trying when unsuccessful, seek out additional information to achieve goals Responsible Decision-Making - identifying problems, accept responsibility for actions, learn from experiences Optimistic Thinking - attitude of confidence, hopefulness, say good things about themselves Check all that applyWhy 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 us?
