Parent/Guardian * Full Name 0 Relationship to child * 1 Do you have legal custody of the child? * 2 Is there a person who shares legal custody of this child? * 3 Name * Full Name 4 Phone Number * with Area Code 5 Are they aware and supportive of the child’s enrollment in the BBBS program? * 6 7 Child's First Name * 8 Middle Name * 9 Last Name * 10 Preferred Name * or Nickname 11 12 Child DOB * 13 What is the child's living situation? * 14 You selected "One-Parent Household." What gender is that parent? * 15 You chose "Other". Please Explain * 16 Home Phone * 17 Parent or Guardian Cell * 18 Child Cell * 19 Is it okay to text parent/guardian? * 20 Is it okay to text child? * 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 32 33 Nationality/Country of Origin * 34 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? * 38 Please check the best number and time to contact you (the parent/guardian) * 39 If we are unable to reach you, who is someone we could call who always knows how to reach you? * 40 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? * 44 Does your child want to participate? * 45 Do you anticipate any significant life changes over the next year or have you had any in the past year, such as moving? * 46 Please Explain: * 47 Will your child be able to meet with their Big one hour a week for the next year? * 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? * 49 Please Explain: * 50 Does your child have siblings or relatives who are applying for the BBBS program at this time or who are currently in the program? * 51 Please provide their name(s): * 52 Number of people (adults and children) in household * 53 Please list anyone living in the home; including their ages and relationship to the child: * 54 Is the parent/guardian receiving income assistance at this time? * 55 Is parent/guardian receiving assistance with housing (e.g. Section 8, residence in public-housing, etc.)? * 56 If living in a housing development, please list the name: * 57 Is child eligible for free or reduced lunch? * 58 Household Annual Income: (total income of the adults the child lives with) * 59 Does your child have a parent/caregiver with current or past military experience? * 60 Please list dates of service * 61 62 63 Is the parent currently deployed? * 64 Date of deployment * 65 Is the parent retired from the military? * 66 Is the parent separated/discharged (other than retired)? * 67 Does your child have a parent/caregiver that is considered fallen, wounded or disabled? * 68 Does your child have a parent/guardian who is currently incarcerated? * 69 Please explain: * 70 If your child is being raised in a single parent home, how did you become a single parent? * 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? * 73 Please explain: * 74 Has your child been physically abused? * 75 By whom and when? * 76 77 Has your child been sexually abused? * 78 By whom and when? * 79 80 Has your child ever been arrested or involved in the juvenile justice system? * 81 Please explain: * 82 Within the last year, has your child been in any trouble at school? * 83 84 Please explain: * 85 Please check those which best describe your child: * 86 Please add any other comments that would describe your child’s personality and behavior: * 87 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 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 97 Parent or Guardian Name * 98 Child's Name * Full Name 99 Date * 100 Submit 101