Community-Based Program Application

Little Brother / Sister Application
Community-Based Program

Mission:

Provide children facing adversity with strong and enduring, professionally supported one-to-one relationships that change their lives for the better, forever.

Community-Based Programs Offered

Big Brothers, Big Sisters, Big Couples (married), and Big Families: These programs are designed to match children between 5 and 15 years old, with an adult who can serve as a positive role model, giving a child a chance to see their unlimited potential and providing the opportunity to develop into a more responsible, successful, well-rounded individual.

Outdoor Adventure Program is designed to instill in children a lifelong enthusiasm and respect for hunting, fishing, wildlife and habitat conservation, and landowner appreciation while providing a complete realistic hunting experience. Hunter safety is emphasized. Children must turn 12 before December 31st of that hunting year.

Campus Kids is a staff supervised group mentoring program specifically for children waiting for a Big Brother or Big Sister. It meets once a week on the SD School of Mines & Technology campus and is led by college student volunteer mentors.

Community-Based Client Application And Parent Permission Form
  • Parent/Guardian*Full Name
    0
  • Relationship to child*
    1
  • Do you have legal custody of the child?*
    Yes
    No
    2
  • Is there a person who shares legal custody of this child?*
    Yes
    No
    3
  • Child Details
    7
  • Child's First Name*
    8
  • Middle Name*
    9
  • Last Name*
    10
  • Preferred Name*or Nickname
    11
  • Gender*
    Male
    Female
    12
  • Child DOB*
    13
  • What is the child's living situation?*
    Two-parent household
    One-parent household
    Group Home
    Other relative of child (non-parent)
    Foster Home
    Other
    14
  • Home Phone*
    17
  • Parent or Guardian Cell*
    18
  • Child Cell*
    19
  • Is it okay to text parent/guardian?*
    Yes
    No
    20
  • Is it okay to text child?*
    Yes
    No
    21
  • Home Street Address*
    22
  • City*
    23
  • County*
    24
  • State*
    25
  • ZIP*
    26
  • Parent or Guardian E-mail*a valid email address
    27
  • Child's E-mail*a valid email address
    28
  • Child's School*Full School Name
    29
  • Grade*
    30
  • Teacher*
    31
  • Child’s Race/Ethnicity*
    American Indian or Alaska Native
    Native Hawaiian or Pacific Islander
    Asian
    White
    Black or African American
    Hispanic or Latino
    Other
    Multi-race
    32
  • Nationality/Country of Origin*
    34
  • Parent/Guardian Details
    35
  • Parent or Guardian Place of Employment*
    36
  • Parent or Guardian Work Phone*
    37
  • May we contact you (the parent/guardian) at the work number listed above?*
    Yes
    No
    38
  • Please check the best number and time to contact you (the parent/guardian)*
    Home
    Cell
    Work
    Morning
    Afternoon
    Evening
    39
  • If we are unable to reach you, who is someone we could call who always knows how to reach you?*
    40
  • Q&A
    41
  • How did you hear about our program?*
    42
  • What is the primary reason for you wanting your child to have a Big Brother or Big Sister?*
    43
  • Does your child know that you are applying for the program?*
    Yes
    No
    44
  • Does your child want to participate?*
    Yes
    No
    45
  • Do you anticipate any significant life changes over the next year or have you had any in the past year, such as moving?*
    Yes
    No
    46
  • Will your child be able to meet with their Big one hour a week for the next year?*
    Yes
    No
    48
  • Does your child have any medical conditions or allergies that might affect him or her participating in activities with a Big Brother/Big Sister?*
    Yes
    No
    49
  • Does your child have siblings or relatives who are applying for the BBBS program at this time or who are currently in the program?*
    Yes
    No
    51
  • Number of people (adults and children) in household*
    53
  • Is the parent/guardian receiving income assistance at this time?*
    Yes
    No
    55
  • Is parent/guardian receiving assistance with housing (e.g. Section 8, residence in public-housing, etc.)?*
    Yes
    No
    56
  • If living in a housing development, please list the name:*
    57
  • Is child eligible for free or reduced lunch?*
    Yes - Free
    Yes - Reduced
    No
    58
  • Household Annual Income: (total income of the adults the child lives with)*
    0-$10,000
    $10,001-$15,000
    $15,001-$20,000
    $20,001-$30,000
    $30,001-$50,000
    $50,001+
    59
  • Does your child have a parent/caregiver with current or past military experience?*
    Yes
    No
    60
  • Does your child have a parent/guardian who is currently incarcerated?*
    Yes
    No
    69
  • If your child is being raised in a single parent home, how did you become a single parent?*
    Divorce
    Death
    Separation
    Desertion
    Never Married
    71
  • Please include date and cause of separation, divorce, or death.*(If Applicable)
    72
  • Have there been any drug or alcohol abuse issues in the child’s family?*
    Yes
    No
    73
  • Has your child been physically abused?*
    Yes
    No
    75
  • Has your child been sexually abused?*
    Yes
    No
    78
  • Has your child ever been arrested or involved in the juvenile justice system?*
    Yes
    No
    81
  • Within the last year, has your child been in any trouble at school?*
    Yes
    No
    83
  • Please check those which best describe your child:*
    Lack’s self confidence
    Wants his/her own way, bossy
    School problems
    Well-behaved
    Responsible
    Assertive
    Aggressive
    Immature for age
    Sensitive
    Hyperactive
    Shy, withdrawn
    Mature for age
    Friendly, outgoing
    Resents authority
    Inactive, sedentary
    86
  • Please add any other comments that would describe your child’s personality and behavior:*
    87
  • CONSENT / UNDERSTANDING
    88
  • By entering my name below, I give permission: 1. For my child to participate in the Big Brothers Big Sisters Program 2. For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to transport my child to events and match activities 3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports) 4. To have my child participate in an in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests 5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety 6. For BBBS staff to provide contact information for me and my child to the volunteer
    89
  • Parent or Guardian Name*
    90
  • Date*
    91
  • Please read the following carefully before signing this application with your typed name below: I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I will be asked to provide additional information through an in-person interview. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information relevant to child-safety and well-being). I certify that all of the information on this form is true and correct and that all income is reported.  I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my qualification for the program. I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me as his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable. If my child is matched with a Big Brother or Big Sister I agree to support my child’s match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff as outlined in expectations (which includes communication at least once a month in the first year of the match), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.
    92
  • Parent or Guardian Name*
    93
  • Date*
    94
  • TALENT / MEDIA RELEASE
    95
  • I hereby consent to the use, sale, reproduction, transfer, or conveyance, of any and all photographs, images, likenesses, and voice recording of me in all forms (with or without the use of my name( by Big Brothers Big Sisters of the Black Hills, or by any designee of the Agency. I hereby consent to the use of all forms of media including advertising, trade, display, editorial, art, exhibition, and Agency newsletters (with or without my photograph and / or my name). I hereby give this consent and release to Big Brothers Big Sisters of the Black Hills, their nominees and designees from liability for any violation of any personal or proprietary right and agree to hold Big Brothers Big Sisters of the Black Hills harmless from all liability from the use, sale, reproduction, transfer or conveyance of the aforementioned items.
    96
  • Please check one*
    I have read this document, understand it is a release of all claims, and consent to the above.
    I do not consent to the above.
    97
  • Parent or Guardian Name*
    98
  • Child's Name*Full Name
    99
  • Date*
    100
  • 101