West High Big Brother/Big Sister Opportunity

 Link to online form

OR

You can print the form below and return to school

Site-Based: Parent/Youth  Enrollment Form

Big Brothers Big Sisters of Dane County does not discriminate on the basis of race, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.

Parent/Guardian Information

Full Name:			Relationship to Child:
	First	Last

Do you have legal custody of the child?  

Is there a person who shares legal custody of this child?      

If yes, are they aware and supportive of the child’s enrollment in the BBBS program?  ☐ Yes     ☐ No

Full Name:

Phone #:

Address:
	Street Address	Apartment/Unit #

	City	State	ZIP Code

Phone:

Email

Cell provider:

Best Time to Call: ☐ Anytime   ☐ Daytime   ☐ Evening   ☐ Weekend  

Are you currently employed outside the home?   

  

Parent Place of Employment:

Work  Phone:

May we contact you (the parent/guardian) at the work number listed?      

Is there a person who shares legal custody of the child? If so, what is their full name?     

May we contact you (the parent/guardian) at the work number listed?      

Child/Little Information

Full Name:				Date of Birth:
	First	Middle	Last

Gender:   ☐ Male   ☐ Female  ☐ Trans Male ☐ Trans Female ☐ Genderqueer/Nonbinary ☐ Prefer not to say

Preferred Pronouns:

Preferred Name:

Child Cell Phone:

Childd Emaill:

Child’s School:

Grade:

Race/Ethnicity  (check all that apply)		☐American Indian or Alaska Native    ☐Asian Indian   ☐Japanese    ☐Korean    ☐Vietnamese     ☐Other Asian    ☐Filipino    ☐Chamorro     ☐Samoan    ☐Native Hawaiian     ☐Other Pacific Islander    ☐Hispanic – Cuban    ☐Hispanic – Mexican, Mexican American, Chicano    ☐Hispanic – Puerto Rican    ☐Hispanic – Other Latinx or Spanish origin    ☐Black or African American    ☐Middle Eastern or North African    ☐White or Caucasian    ☐Prefer not to say     ☐Some other race or origin – please list:
Nationality:

Child’s Living Situation:

☐ Two-parent household     ☐ One-parent household (☐Female / ☐Male)    ☐ Other relative of child (non-parent)    ☐ Foster Home     ☐ Group Home     ☐ Other:

Does your child experience any of the following Dietary Modifications : Chronic Illness: Physical Limits: Behavioral Concerns: Developmental Delays:

Emergency Contact Name:			Phone:
Relation to child:

Pre-Interview Questionnaire

What is the primary reason for you wanting your child to have a Big Brother or Big Sister?

Please list 3 goals you hope your child can attain by having a Big Brother/Sister

Does your child know that you are applying for the program? Does your child want to participate?

What are your child’s interests and favorite activities?

Is there anything about your child that you’d like us to know as we search for the right match for them? (Preferences, personality, interests)

Languages spoken by parent and child:

Where did you hear about us?

☐ Family   ☐ Friend   ☐ BBBS staff   ☐ Event – please indicate the event:

☐ Work/School    ☐ Therapist    ☐ Website    ☐ TV/Radio    ☐ Service Organization    ☐ Faith Organization    ☐ I was a Little    ☐ Other family involved in the program     ☐ Other – please explain:

Does your child have siblings or relatives who are applying for the BBBS program at this time, or who are currently or were previously in the program?		YES ☐	NO ☐
If yes, please provide their names:

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 ☐
If yes, please explain:

Will your child be able to meet with their Big once per week at the school?

YES ☐

NO ☐

Does your child have any medical conditions that might affect him or her participating in activities with a Big? (this includes a diagnosis or any emotional or behavioral conditions, like: ADHD, PTSD, bipolar disorder, etc.)		YES ☐	NO ☐
If yes, please explain:

Household Information

Number of people (adults and children) in household:

Is the parent/guardian receiving income assistance at this time (SSI, SNAP, etc.)?

YES ☐

NO ☐

Is the parent/guardian receiving assistance with housing (Section 8, residence in public housing, etc.)?		YES ☐	NO ☐
If living in a housing development, please list the name:

Is child eligible for free or reduced lunch?

YES ☐

NO ☐

Household Annual Income: (total income of the adults with child lives with)

☐$0 - $10,000   ☐$10,000 - #14,999   ☐$15,000 - $19,999   ☐$20,000 - $24,999   ☐$25,000 - $29,999 ☐$30,000 - $34,999   ☐$35,000 - $39,999   ☐$40,000 - $44,999   ☐$45,000 - $49,999   ☐$50,000 - $59,999  ☐$60,000 -  $74,999   ☐$75,000 - $99,999   ☐$100,000 - $124,999   ☐$125,000 - $149,999   ☐$150,000 - $199,000 ☐$200,000 or more

Does your child have a parent/caregiver with current or past military experience?								YES ☐		NO ☐
If yes, please list dates of service:
Is the parent currently deployed?				☐Yes     ☐No	Date of deployment:
Branch:	☐Air Force    ☐Army    ☐Marine Corps    ☐Navy    ☐Coast Guard
Component:		☐Active    ☐National Guard    ☐Reserve
Retired:	☐Yes    ☐No		Separated/discharged (other than retired)		☐Yes    ☐No	Fallen/wounded/disabled			☐Yes    ☐No

Does your child have a parent/guardian who is currently incarcerated?			YES ☐	NO ☐
If yes, please explain:
If yes, where:

Has your child ever been arrested or involved in the juvenile justice system?		YES ☐	NO ☐
If yes, please explain:

Disclaimer and Signature

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 provide mentorship to my child at my child’s school.;

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 Big Brothers Big Sisters 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, including Big Brothers Big Sisters of America. I understand that Big Brothers Big Sisters does not exclude children from this program on the basis of: race, religion, national origin, color, gender, marital status of the parent, sexual orientation, gender identity, veteran status, immigration status, or disability. 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.

Print Name:
Parent/Guardian Signature:		Date:

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 that 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.

Print Name:
Parent/Guardian Signature:		Date:

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.

I hereby authorize Big Brothers Big Sisters of Dane County to use my or my child’s image, voice, and/or performance to promote the Big Brothers Big Sisters program. I agree that there will be no compensation whatsoever for this participation or for the use of resulting materials by Big Brothers Big Sisters. I further agree that this participation confers no ownership rights. Big Brothers Big Sisters of Dane County releases me from all liabilities or claims that may result from the existence and use of any such materials. 

Print Name:
Parent/Guardian Signature:		Date: