PARENT/YOUTH APPLICATION

Child's Full Name (Legal Name)

Parent/Guardian's Name

Parent’s Relationship to child:

Parent's Relationship to Child:

Mother Father Grandparent Fosterparent

Parent's Date of Birth

Date

Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone

Cell Phone

Best Time to Call

Email address

example@example.com

Preferred method of communication

Text Phone Email

Is Parent Receiving Income Assistance?

Yes No

If Yes, what type of assistance (i.e., food stamps, SSI, WIC etc.)

Parent's Place of Employment

Work Phone

Youth's Date of Birth

Date

Emergency Name & Phone

Youth's Gender Assigned at Birth

Youth's Race/Ethnicity

African American/Black American Indian Asian Hispanic Prefer not to say

School

Grade

Graduation Year

Free/Reduced Lunch

Yes No

Special Education

Yes No

Insurance & ID #

Child's Medications/Allergies

Who referred you to BBBS?

Relationship

Phone

List names and ages of others in household

1. What is the primary reason why you want your child to have a Big Brother/Big Sister?

2. What is your living situation?

Two-Parent Household Single-Parent, Female Single-Parent, Male Other Relative (Kinship Care) Foster Home Group Home

3. Does your child have any medical conditions that might affect him or her participating in activities with a Big Brother/Big Sister?

3. Does your child have any medical conditions that might impact him/her participating in activities with a Big Brother or Big Sister?

Yes No

If yes, please describe:

4. Does you anticipate any significant life changes over the next year or had major changes in the past year?

Yes No

If yes, please explain:

5. Information regarding absent parent:

Name

Date of Birth

Date

Address

Street Address Line 2

City/Zip

Country

Absent Parent's Gender

Male Female Non-binary

Absent Parent's Race

How often does he/she see your child?

Weekly Monthly Almost never Never

Is the absent parent in agreement with your request for a Big Brother/Sister for your child?

Yes No n/a

6. We have a special program (Amachi Program) for children who have been impacted by parental incarceration. Would this program apply to your child?

Yes No

7. Has your child had prior involvement with the Juvenile Justice System?

Yes No

If yes, please list # of times and when:

For Big Brothers Big Sisters Community-Based Mentoring Programs: I hereby give my permission to release information regarding myself and/or my child to a volunteer Big Brother/Big Sister. This release applies to the referral source, school officials, counseling/health agencies, or Dept. of Human Services as it pertains to matching my child with a volunteer. I authorize my child’s school to release grades and attendance records to Big Brothers Big Sisters.

I give my permission for Big Brothers Big Sisters of Flint & Genesee County, Big Brothers Big Sisters of America, and their funders to utilize any photos, audio tapes, video images or other images/recordings; academic achievement, school attendance for promotional, reporting and other purposes.

For Big Brothers Big Sisters After-School Program or Lunch Buddy Program: I give permission (1) for my child to participate in the Big Brothers Big Sisters Program; (2) for the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports) and discuss the health of match relationship; (3) to have my child complete a questionnaire containing questions about school, home life, and personal interests; (4) to have my child talk with a Big Brothers Big Sisters staff person about personal safety; and (5) to use my child's photograph and first name for the purpose of publicity efforts by Big Brothers Big Sisters. I understand that all in-person contact between the child and volunteer will be at the child’s school only.

Parent/Guardian Signature:

Clear

Date:

Date

Big Brothers Big Sisters of Flint & Genesee County 1176 Robert T. Longway Blvd. Flint, MI 48503 (810) 235-0617 Rev. 02/2020