Child Application

Eligibility
I understand that PEACE Inc, Big Brothers Big Sisters has the following criteria for applicants:*

My child is between the ages of 8 and 15.My family resides in Onondaga County.My child is enrolled in and attending school.My family has an income below 200% of the Federal Poverty Line (see below)
If you have any questions about the above requirements, please reach out to Phineas Penzo (Program Assistant) at phineas.penzo@peace-caa.org or by calling (315) 470-3369, ext 155.

Parent Information
Parent/Guardian Name*

First NameLast Name
Maiden Name
(if applicable)
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Marital Status*
Religious Preference
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type*

CellHome
Email*
example@example.com
Occupation*
Business/Employer*
(if unemployed, put "n/a")
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Household income*
I will submit the following proof of income:*

Medicaid CardOther Benefits Statement/Award LetterPaystubs for four weeks of payW-2 or other tax form that states annual incomeOther

Emergency Contact
We must have an emergency contact on file for every Little in our program.

Please do not list the same person as both parent/guardian and emergency contact.
In case of Emergency Contact*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

I acknowledge and agree to the following:
- No fees will be charged for the Big Brothers Big Sisters Program
- The volunteer assumes no legal or financial liabilities
- The program is under no obligation to assign a volunteer to my child
- The information on this application is true and complete to the best of my knowledge
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*
Date*

MonthDayYear
Date
THE INFORMATION ON THIS APPLICATION IS STRICTLY CONFIDENTIAL AND WILL NOT BE RELEASED WITHOUT YOUR PERMISSION.

Big Brothers Big Sisters of Onondaga County follows a non-discrimination policy that prohibits exclusion of potential Volunteers, Advisory Council members, youth or parents/guardians on the basis of race, color, age, religion, national origin, gender, marital status, sexual orientation, veteran status, or disability. Our volunteer selection policy is to honor the preference of the parents/guardians who bring their children to us for services.
Parent/Guardian approves the proposed match.

BBBS RESERVES THE RIGHT TO ACCEPT OR REJECT ANY APPLICATION AT ITS OWN DISCRETION.
Should be Empty:

Eligibility