CB Mentee Application

Community Based Mentee Application

(to be completed by the Parent/Caregiver)

Child's Full Name*

Preferred Name

How does your young person identify male female transgender twospirited etc

Which pronoun should be used to identify your child youth he she they etc*

Child's Date of Birth M/D/Y*

Date

Age*

Parent/Caregiver Full Name (person completing this application):

Name*

First NameLast Name

Pronouns*

Relationship to child*

Home Address*

Primary Phone Number*

Format: (000) 000-0000.

Please list any other numbers where you could be reached:

1

2

3

Email*

example@example.com

Languages Spoken

Preferred language

Emergency Contact (if available):

Name

Phone Number

Format: (000) 000-0000.

Relationship to young person

Big Brothers Big Sisters and Your Young Person:

Is your young person aware of your application for a Big Brother Big Sister?

If yes what was the reaction*

In what ways do you feel your young person would benefit from participating in the Big Brothers Big Sisters Mentoring Program*

Does anything prevent your young person from fully participating in the program?

If yes, please explain:

How did you hear about Big Brothers Big Sisters*

If your young person attends inperson school what school do they attend and what grade

Thank you for your interest in Big Brothers Big Sisters. Please sign and date this form:

Date*

Date