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2019-09-10T18:30:55+00:00
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Child's Information
Child's First Name
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Child's Gender
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Yearly House Hold Income
How many people live in your home?
Is either parent incarcerated?
Yes
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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?