Child's First Name                                                                                  

Child's Middle Name                                        

Child's Last Name                                       

Date of Birth                                               

Child's Current Age                                     

Social Security Number                                   

Gender                                                        Female Male

Ethnicity                                                    African American Asian Caucasian Hispanic Mixed Race Other

Address                                                       

City                                                            

State                                                         

Zip                                                           

Home Phone                                              

Religious Affiliation                                   

Name of School                                          

Grade                                                        

Teacher                                                       

Child's Physician                                       

Phone                                                      

Allergies/Illnesses                                      

Prescribed Medication and Dosage                                

Has the child been seen by a councilor or therapist in the last year?        Yes No

Name                                                       

Full Address                                               

Date last seen                                            

Parent/Guardian Information

Full Name                                                                                           

Relationship to Child                                

Parent/Guardian Date of Birth                     

Employer                                                

Employer Full Address                             

Occupation                                             

What hours do you work?                         

Work Phone                                           

May we call you at work?                          Yes No

Income Level                                           $5,000-$9,999 $10,000-$14,999 $15,000-$19,999 $20,000-$29,999 $30,000 +

Marital Status                                         Single Seperated Divorced Married Widowed Co-Habitating

Years Separated/Divorced/Widowed           

Education                                               Less than High School GED High School Diploma Technical Diploma Associates Degree Bachelors Degree Graduate Degre

Absent Parent Information

Full Name                                                   

Race                                                      African American Asian Caucasian Hispanic Mixed Race Other

Full Address                                         

Home Phone                                           

Work Phone                                         

Frequency of Contact With Child              Weekly Bi-Monthly Monthly Yearly No Contact

Is the absent parent incarcerated?               Yes No

Emergency Contact

Full Name                                           

Relationship to Child                            

Phone                                                 

Full Address                                        

I hereby request that my child be included in the Big Brothers Big Sisters of the Chattahoochee Valley program and consent to his or her participation in any activity offered by the program. I further agree that some information contained herein and other information gathered shall be shared with the perspective Big Brother or Big Sister, but names and identities shall be withheld until the match is agreed upon by all parties involved. I further agree to the sharing of pertinent information as deemed necessary about my child, myself, and/or my family with my child's Big Brother or Big Sister by professional staff of the agency during the course of my child's match. Sharing of such information shall be in efforts to provide an effective ongoing match through supervision and support services.

I understand that I am free to withdraw my child's application for service at any time and also may withdraw my child from the program at any time I wish. I further understand that Big Brothers Big Sisters of the Chattahoochee Valley may not be able to complete a match with a volunteer for my child.

In additional consideration of my child's participation in the Big Brothers Big Sisters program or sponsored activities I do hereby provide this is a covenant that I will not make claims or demands of the program for myself or on the behalf of my child against Big Brothers Big Sisters, the Family Center, professional staff, or any member thereof which may occur during participation directly or indirectly in the activities of the program. I hereby consent that in the event that my child requires immediate medical treatment, and in my absence, any member of Big Brothers Big Sisters may give authorization for such treatment as deemed necessary by a licensed physician for emergency situations. 

I have read , understand, and agree to the above criteria for my child's eligibility and participation in the Big Brothers Big Sisters of the Chattahoochee Valley program.                  Yes No