Non-Discrimination Policy

All BBBS participants, including youth, families, volunteers, board and staff serving as volunteer Bigs are not excluded on the basis of race, ethnicity, religion, national origin, color, gender, marital status, sexual orientation, gender identity, gender expression, citizenship status, veteran status, or disability.

CHILD APPLICATION

All information on this application is confidential. We use this information to assist in matching your child and for grant funding only.

Child Information

First Name

Middle Name

Last Name

Suffix

e.g. Jr, III

Preferred Name

Birthdate

Enter a date in the following format: mm/dd/yyyy

Gender	Personal Pronouns
How does the child identify?	What pronouns does the child use?

Race/Ethnicity

Press CTRL while choosing to select multiple

School

Expected HS Graduation Year*

*To find your child's expected HS Graduation Year by grade Click Here

Does the child have their own phone?

YesNo

Child's Phone

Enter numbers only starting with the 3 digit area code.

After being matched, may we contact your child directly on their phone regarding their match?

YesNo

Does the child have their own email address?

YesNo

Child's Email Address:

After being matched, may we contact your child directly through their email regarding their match?

YesNo

National Origin: Is the child an immigrant/refugee?

YesNo

Please list child's country of birth

Has the child ever been involved with the police or juvenile justice system?

YesNo

What was their involvement?

Does the child have a parent/guardian/caregiver who is currently incarcerated?

YesNo

How is the parent/guardian/caregiver related to child?

e.g. father, mother, step-father, aunt etc

Does the child have a parent/guardian/caregiver that has a history of incarceration?

YesNo

How is the parent/guardian/caregiver related to child?

e.g. father, mother, step-father, aunt etc

Child Living Situation

Living Situation Description

Does the child have a parent/guardian who is serving in the military or considered a veteran?

Is the child's parent/guardian currently deployed?

YesNo

Guardian Information

Guardian Contact ID

Guardian's Relationship to Youth

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Birthdate:

Input format: mm/dd/yyyy

Preferred Language:

English	Spanish
African Languages (Swahili, Bantu)	American Sign Language
Arabic	Asian: Other
Chinese	Creole
Dutch	Eastern European (Czech, Slovak)
French	German
Greek	Hebrew
Hmong	Indian (Hindi, Punjabi)
Italian	Japanese
Keres (West)	Korean
Nordic	Persian
Portuguese	Russian
Turkish	Lao

Mobile Phone

Enter numbers only starting with the 3 digit area code.

Home Phone

Enter numbers only starting with the 3 digit area code.

Work Phone

Enter numbers only starting with the 3 digit area code.

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Work Email

Alternate Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

Is there a person who shares custody of this child?

YesNo

Name:

Relationship to Child:

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Please select the county in which you reside:

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

State

Zip Code

Annual Household Income

How many people are currently living in your household?

Please list all household members name, age and relationship to child:

Is the child eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

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

YesNo

Please Describe:

Existing Household Members

Please choose this child's relationship to the following people:

Name:	Relationship:
App record ID	contact record ID

Emergency Contact

In the event you cannot be reached please provide an emergency contact:

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

The following information will help assist us in matching your child to a screened Big (volunteer).

Is the child taking any medications?

YesNo

Medications Description

Does the child have any allergies?

YesNo

Allergies Description

Child's Mental Health Diagnoses:

None	Agoraphobia
Anxiety/Panic	Bipolar Disorder
Depression	Obsessive Compulsive Disorder (OCD)
Oppositional Defiance Disorder (ODD)	PTSD
Schizophrenia	Suicidal Ideation
Tourette Syndrome	Other

Check all that apply

Other - please describe:

Child's Developmental Diagnoses:

None	ADD
ADHD	Asperger’s Syndrome
Autism	Dyslexia
Cerebral Palsy	Hearing Impairment
Intellectual Disability	Learning Disability
Memory Loss	Traumatic Brain Injury
Visual Impairment	Other

Check all that apply

Other - please describe:

Child's Exposure to Trauma:

None	Alcohol Addiction
Bullying	Community Violence
Death of a Parent	Domestic Abuse
Drug Addiction	Emotional Abuse
Homelessness	Neglect
Physical Abuse	Sexual Abuse
Other

Check all that apply

Other - please describe:

Chronic Illnesses:

None	Cancer
Chronic or Acute Asthma	Diabetes
Heart Condition	HIV/AIDS

Does your child have any other medical conditions not listed above?

YesNo

Please describe:

Which activities does the youth enjoy more?

How would you describe the youth, in terms of participation in events, activities, or sports?

I would like my child to feel empowered with the following:

Self-Awareness - identifying emotions, ask for feedback, desire for self-improvement Self-Management - impulse control, stress management, self-motivation/discipline, organizational skillsPersonal Responsibility - remembering important information, handle belongings with careSocial Awareness - empathy, respect for others, appreciating diversityRelationship Skills - communication, social engagement, relationship building, teamworkGoal-Directed Behavior - keep trying when unsuccessful, seek out additional information to achieve goalsResponsible Decision-Making - identifying problems, accept responsibility for actions, learn from experiencesOptimistic Thinking - attitude of confidence, hopefulness, say good things about themselvesCheck all that apply

Why would you like your child to have a Big Brother/Big Sister?

Please include any additional information that would be helpful for your child's Big to know:

How did you hear about us?

Hidden Fields

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Stage:

Media Release

I, the legal parent or guardian of the Little I am enrolling (“Minor Child”), irrevocably consent for myself and Minor Child to any and all uses and displays of my or Minor Child’s name, image, likeness, appearance, and basic biographical information in, on, or in connection with any advertising, publicity, marketing, or printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America, BBBSKY, and any of their affiliates, successors, partners, sponsors, donors, and any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type without further consent from me or Minor Child, without any royalty, payment, or other compensation to me or Minor Child, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use. I understand that it is my responsibility to contact Big Brothers Big Sisters of Kentuckiana if I no longer wish for my child to participate in media related activities.

YesNo, Opt Out

Confidentiality Policy & Permission Form

Confidentiality & Obligation Release - Parents and Guardians

Confidentiality

The Big Brothers Big Sisters agency respects the confidentiality of youth and parent records and shares this information only among agency professional staff, except where legally required. State law mandates that suspected child abuse be reported to the appropriate authorities.

I understand that:

Any information that reveals my or my child’s identity will be held confidential.
For purposes of program evaluation, audit, or accreditation, certain bodies such as BBBS of America or National Student Clearinghouse (NSC) may have access to my child’s records. NSC will produce aggregate reports to BBBS on the number of students who move on to post-secondary education. I will inform BBBS if I choose to opt-out.
Any school, clinical, or medical records of any kind will be held confidential.
Information will be released to other individuals and organizations only upon presentation of an authorized “consent to release information” form signed by me.
All records are considered property of the agency.
Information about potential volunteers that may be shared with the youth and guardian will include the volunteer’s age, gender, race/ethnicity, religious affiliation, interests and hobbies, contact information, family and living situation, experience with children, medical/mental health status, sexual orientation, criminal background, substance use, reason for involvement, input from collateral contacts(references, mental health professionals, agency staff), and an overall summary of why the volunteer was chosen for the match.
Information about the potential Little Brother or Little Sister that may be shared with the volunteer will include the same categories as volunteers, along with a summary of needs, expectations for match participation, and anticipated challenges the volunteer may encounter.
I will NOT discuss additional information that I may encounter about the volunteer without permission of agency staff.
Agency staff will hold my child’s disclosures related to the child’s gender identity and/or sexual orientation confidential if my child does not want that information shared with me. Agency staff will encourage my child to find a safe and supported way to share this information with me when the child is ready to do so.

Obligation Release & Permission to Participate

I give permission for my child to participate in the Big Brothers Big Sisters program.

I understand that:

The agency is not obligated to match my child with a volunteer.
I am in no way obligated to participate in this program, nor is my child.
To protect the confidentiality of clinical and school reports, the agency will notify the parent of non-acceptance by letter, but it is not obligated to disclose the reason for non-acceptance.
Parents and guardians must sign this statement in order to participate in the program.
My child and I must participate in an enrollment process which includes an orientation, interview, and review of safety information
No fees are charged for requesting a Big Brother/Big Sister.
As a Parent/Guardian, you may now receive emails and/or text messages inviting you and your family to agency activities and events.

Confidentiality Waiver

I have read, understand and agree to the above statements. I release and waive my liability against the organization and its staff.

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Contact Information

CHILD APPLICATION

The following information will help assist us in matching your child to a screened Big (volunteer).

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