PARENT/YOUTH APPLICATION

PARENT/YOUTH APPLICATION
Child's Full Name (Legal Name)
Parent/Guardian's Name
Parent's Relationship to Child:

Mother Father Grandparent Fosterparent
Parent's Date of Birth

Month Day Year
Date
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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

Month Day Year
Date
Emergency Name & Phone
Youth's Gender Assigned at Birth
Youth's Race/Ethnicity

African American/Black American Indian Asian Caucasian/White 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 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

Month Day Year
Date
Address

Address

Street Address Line 2

City/Zip
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:

Month Day Year
Date
Big Brothers Big Sisters of Flint & Genesee County 1176 Robert T. Longway Blvd. Flint, MI 48503 (810) 235-0617 Rev. 02/2020
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm