Enroll a Child

Parent/Youth Pre-Interview Questionaire


Parent/ Guardian's Name:*
Child's Name:*
Home Address:*
Street:
City:
County:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:*
Youth's Date of Birth:
Youth's Gender:
Youth's Race:
Parent/ Guardian's Place of Employment:
Best time to call:
Is the family receiving income assistance?


If "Yes", please indicate type of assistance:





This is for data collection purposes only and not for program eligibility. Please indicate annual family income:









What is your current living situation?








What is the primary reason for wanting your child to have a Big Brother or Big Sister?
Does your child have any medical conditions that might affect him/her from participating in activities with a Big Brother or Big Sister?


If yes, please describe:
Is there a person who shares custody of this child?


If yes, are they aware of the child's enrollment in BBBS?


Do you anticipate any significant life changes over the next year or have you had any in the past year?


If yes, please describe:
Does the child have one or both parents/ guardians currently incarcerated in a State or Federal facility?


We have a special program for children of incarerated parents. Would this program apply to your child?


By signing 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. 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. *

Date:
Enter the text you see in the security image: