Community-Based Little Application

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This field is for validation purposes and should be left unchanged.
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

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 Parent
Name:
First Last
Address:
Street Address Address Line 2 City Province Postal Code
Phone
Email:
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:

Medical History
Does 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:

Parent/Guardian Information