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Be A Little Formcourtland fusion2019-09-10T18:30:55+00:00

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Guardian Information

Guardian First Name

Guardian Last Name

Guardian Email

Guardian Mobile Phone

Guardian Street Address

City

Zip Code

State

Spanish Preferred?

Yes

No

Child's Information

Child's First Name

Child's Last Name

Your Relationship to Child

Child's Date of Birth

Child's Gender *

Female

Male

Non-Binary

Prefer to self-describe

Ethnicity

Living Situation

Single Parent

Both Parents

Grandparents

Other

Yearly House Hold Income

How many people live in your home?

Is either parent incarcerated?

Yes

No

Is either parent an active military member or do they have past military experience?

Does your child qualify for free or reduced lunch?

Yes

No

Is your child seeing a therapist or counselor?

Yes

No

Are you and/or your child a refugee?

Yes

No

Has the child been hospitalized within the last six months? If yes, please explain.

Why would you like your child enrolled in our program?

How do you think your child will benefit from having a Big Brother/Sister?

Is your child aware of their potential enrollment? Please describe their interest level and if they are excited about this opportunity.

Does your child have any barriers to participating fully in the program or advocating for himself? This would include but not limited to intellectual or learning delays, autism, or other mental diagnosis.

Does your child have any behavioral issues?

Are there any siblings already enrolled in BBBS?

Yes

No

If yes, how many?

I have completed the child abuse safety training. Click here to complete it.

I have read and understand the information on the previous page.

I Agree

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