1:1 In the Community – Enrol a Young Person Step 1 of 3 33% Please note that currently we are only accepting applications for female identifying children and youth. If an application is submitted for a male identifying child or youth, the application will be discarded.* I acknowledge that if I submit an application for a male identifying youth, the application will be discarded. As our mentors are volunteers from the community and not professionals, we recognize that our scope is limited and cannot meet all children's and youth's needs. To ensure that your child/youth is a fit for the program, please review the criteria below (children and youth must meet all criteria to be eligible for our programming):* My child is 7 years of age or older at the time of this application. * I am the legal guardian of the child I am referring. * My child is able to communicate and manage self-care independently (i.e. toileting, hygiene, etc.). * My child is able to understand and remember messages around safety such as boundaries and secrets. * My child does not display behaviors that can put themselves or others at risk. (examples: aggressive behaviors and language, a history of running away, not listening). * My child has the ability to build a positive and healthy relationships with a mentor. I understand that Big Brothers Big Sisters of London and Area is under no obligation to accept my child or youth/provide my child or youth with a mentor.* I understand. I understand that if accepted, Big Brothers Big Sisters of London and Area will do everything they can to provide a match, but a 1:1 match may not always be possible. Agency staff will share other potential opportunities my child may be eligible for (e.g. group programming, agency activities).* I understand. I understand that an inability to maintain contact with the agency could result in the termination of my child's/youth's application and/or closure of their file/match.* I understand. I understand that it is my responsibility to keep Big Brothers Big Sisters of London and Area updated if any information changes (address, phone number, email, etc.).* I understand. MENTEE APPLICATION FORM (1:1 IN THE COMMUNITY)To be completed by the legal parent/guardian ONLYCHILD INFORMATIONChild's Legal Name (first & last name)* Child's Preferred Name (first & last name)* Date of Birth (DD-MM-YY) (must be at least 7 years old at time of application)* Gender* Preferred Pronouns Languages Spoken* Ethnicity Immigrant Yes No Allergies or Medical Notes*Address* Street Address City Province Postal Code Cell Phone Home Phone Email School* Grade* Does your child currently have a mentor through another Big Brothers Big Sisters program?* Yes No *mentees are only eligible to be matched in one program at a timeParent/Guardian InformationFull Name(s)* Relationship to child* Custody details (none, joint, sole etc.)* If your child does not live with both parents, what type of relationship does your child have with the other parent(s)?*Is the other parent aware of your application for the program?* Yes No If yes, what is their attitude? If no, why not?*Age(s) of sibling(s)? Does your child live with their siblings? Yes No Who else lives in the home?* Emergency Contact InformationEmergency Contact (other than legal guardian)* Cell Phone Home Phone Work Phone Relationship to Child* Are you or your child involved with any other community agency or supports?* Yes No If yes, please list them here:Who referred you to BBBS? (teacher, friend, doctor, self, etc.)* Does anything prevent your child from fully participating in the program?* Yes No If yes, please explain: Is your child aware of your application for a Big Brother Big Sister?* Yes No If yes, what was the reaction?Tell us about your child and what is great about them!*How do you think your child would benefit from having a mentor in their life?*Additional Comments:Name First Last Date MM slash DD slash YYYY Consent* I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area's Privacy and Confidentiality Policy.NameThis field is for validation purposes and should be left unchanged. Facebook Twitter Google+ LinkedIn
