1:1 In the Community – Enroll a Young Person Step 1 of 2 50% CommentsThis field is for validation purposes and should be left unchanged.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 between 7 and 15 years old 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 PronounsLanguages Spoken*EthnicityImmigrant Yes No Allergies or Medical Notes*Child's Address (Primary Residence)* Street Address City Province Postal Code 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(s) InformationPlease select the most appropriate answer This child lives with more than one legal parent/guardian This child primarily lives with one parent/guardian who shares joint custody with another parent/guardian This child lives with one parent/guardian who has sole custody, but has contact with another parent/guardian This child lives with one parent/guardian who has sole custody, and does not have contact with another parent/guardian Other Please explain the custody arrangement of this child*Parent/Guardian 1 - Full Name*Parent/Guardian 1 - Relationship to child*Parent/Guardian 1 - Cell Phone*Parent/Guardian 1 - Home PhoneParent/Guardian 1 - Email Parent/Guardian 2 - Full Name*Parent/Guardian 2 - Relationship to child*Parent/Guardian 2 - Cell Phone*Parent/Guardian 2 - Home PhoneParent/Guardian 2 - Address* Street Address City State / Province / Region ZIP / Postal Code Parent/Guardian 2 - Email What type of relationship does your child have with the other parent/guardian(s)?*Is the other parent/guardian aware of your application for the program?* Yes No If yes, what is their attitude? If no, why not?*Does your child live with their siblings? Yes No N/A Age(s) of sibling(s)?Who else lives in the home?*Emergency Contact InformationEmergency Contact (other than legal guardian)*Phone Number*Relationship to Child*Are you or your child involved with any other community agency or supports?* Yes No Please list the community agencies or supports here:*Who referred you to BBBS? (teacher, friend, doctor, self, etc.)*Does anything prevent your child from fully participating in the program?* Yes No Please explain:*Is your child aware of your application for a Big Brother or Big Sister?* Yes No What was their 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:Parent/Guardian Name (first & last name)*Today's 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.Parent/Guardian Signature*SMS Verification* Share: Facebook Google+ LinkedIn
