Community-Based Little Application Step 1 of 7 14% Thank you for your interest in enrolling a young person as a little. Please review the following checklist to ensure you understand the requirements and commitment involved in becoming a part of our program. The application will follow this checklist. Please call us at 368-5437 if you have any questions while completing this application.The child I am enrolling wishes to be a part of the mentoring program with Big Brothers Big Sisters* Yes No The child I am enrolling is currently between the ages of 6-16* Yes No The child I am enrolling is able to communicate verbally, perform independent self-care and can maintain a healthy relationship, understanding and respecting boundaries* Yes No Does the child you are enrolling have any presenting behaviors that could put them or a volunteer at risk of harm?* Yes No I understand that BBBS may request referrals from any professionals or agencies involved with the child* Yes No I understand that there is no obligation for BBBS to accept a child* Yes No I understand that if I share custody of my child with another parent, consent from that parent will be needed to proceed* Yes No I understand the processing time to enroll & match a child could vary and is different for each child* Yes No Child’s Full Name:* First Last Date of Birth:* MM slash DD slash YYYY Age:*Please enter a number from 6 to 18.Place of birth:* Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone:*Work Phone:Cell Phone:*Home Email:* Emergency Contact:* (emergency contact must be someone other than you)Phone:*Relationship to Child:* Which volunteer would you prefer for your child? Check all that apply* Select All Big Brother Big Sister Big Couple (if available) PRISM Mentor Parent/Guardian InformationParent/Guardian Name:* First Last If Guardian, please note relationship to child: Date of Birth:* MM slash DD slash YYYY Marital Status:* Are you employed?* Yes No Place of employment: Work Phone:Are you unemployed? EI Social Assistance Disability Other If "other": Are you a student?* Yes No If yes, where? If a custody arrangement exists, please indicate which of the following applies to the child you are enrolling:* Joint Sole None Child is in care of CSSD Please note If joint custody is in place, you must notify the other parent of this application. Both parents who are involved in a child’s life must approve the child’s involvement with the agency in order to provide service.Information about other ParentName: First Last Address: Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneEmail: What type of relationship does your child have with the other parent?If you are a single parent with custody, what are the visiting rights of the other parent? Does he/she use these rights? What are the access arrangements?In your view, does your child have a close relationship with the other parent? Is the other parent aware of your application for the program? Yes No If yes, what is his/her attitude? If no, why not?Other parent’s marital status: Family History/SituationAre there other people living in the home? Yes No Name First Last AgeGender Relationship If under 16, are they also applying? Y/N Does anyone else live in the home? Yes No Name First Last AgeGender Relationship If under 14, are they also applying? Y/N How long has your child lived in your current home?* Has your child ever lived outside of your home?* Yes No If so, please provide detailsDo you currently have involvement/support from CSSD (Formerly Child, Youth & Family Services)?* Yes No If yes, please provide Social Worker's name and contact information:Does anything prevent your child from fully participating in the program?* Yes No Please explain: Medical HistoryDoes your child have any medical conditions, allergies, or other diagnoses?* Yes No If yes, please explain:Is your child on any medication?* Yes No If yes, please explain:Has your child ever seen or is your child now seeing a psychologist, social worker, therapist, counsellor, CMS, BMS, etc.?* Yes No If yes, please explain (include approximate dates, contact information of worker):Do you think your child has any emotional difficulties? Yes No If yes, please explain: School InformationSchool:* Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Grade:* Teacher:* Does your child seem interested in school?* Yes No Has your child ever been involved in a special education program?* Yes No If yes, please comment:Does your child get in trouble at school?* Yes No If yes, is it often? occasionally? seldom? Social ActivitiesAre you or your child involved with any other community agency?* Yes No Agency Name PhonePlease indicate what activities your child currently enjoys.*Briefly describe your child’s weekly schedule of activities.*Is there anything you would like us to be aware of if that would assist us in finding the right mentor for your child?*ConfidentialityJust as we have to share information with you about the Big Brother Big Sister we select for your child, we need to share information with the volunteer about you and your child to ensure a suitable match is identified. Is there any information that you do not want shared with a volunteer?* Yes No If yes, please clearly state what you do not want shared:Parent/Guardian SignatureName First Last Date MM slash DD slash YYYY The answers you have given will help us to do our best for your child. Please be sure to advise us of any changes in your home situation, such as address changes, relationship changes, etc. Please include a recent photo of your child with (the photo will not be shared. It will simply be attached to your file and will allow us to put a name and face together when identifying a match.)*The answers you have given will help us to do our best for your child. Please be sure to advise us of any changes in your home situation, such as address changes, relationship changes, etc. Please include a recent photo of your child with (the photo will not be shared. It will simply be attached to your file and will allow us to put a name and face together when identifying a match.) I agreeEmailThis field is for validation purposes and should be left unchanged. Facebook Twitter Google+ LinkedIn
