Enrollment Application Form Enroll a Young Person "*" indicates required fields Step 1 of 6 16% Program of Interest*Please select all that apply. Big Brothers (One-to-One Programming) Big Sisters (One-to-One Programming) Big Bunch (Group Programming) Child's InformationPreferred Name Legal Name* First Middle Last Date of Birth* MM slash DD slash YYYY Must be between 6 and 16 years of age.Gender School* Grade*Please enter a number from 1 to 12.Languages Spoken* Add RemovePrevious Involvement*Has your child been previously involved with any Big Brothers Big Sisters agency in Canada? Yes No Which Agency/City?* Which year(s)?* Child's Medical InformationHealth Card Number* Medical Notes*Does the child have any dietary restrictions, allergies, or any other medical notes that would affect participation in programming? Yes No Medical Notes*Please describe medical notes stated above.Medical Authorization*I, hereby, give permission to hospital and/or clinic staff to administer all reasonable and necessary medical care, in case of injury or illness to my child, while in the care of his/her Big Brother/Big Sister, in the event that I cannot be reached. I agree with the statement above. Medical Authorization E-Signature* Primary Caregiver (With Legal Custody) InformationName* First Last Is this a non-residential parent?* Home Phone*Mobile PhoneBusiness PhonePlease include Ext. #Please include Ext. #Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code How Long Have You Been at Your Current Address?* Employer/School* Occupation/Field of Study* What is Your Primary Means of Transportation?* Other Caregiver InformationName First Last Relationship to the Child Address Same as previous Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Is the non-residential parent aware of your application with this agency? Yes No Would the non-residential parent be supportive of this application? Yes No Custody and Access InformationLegal Guardian's Custody*Sole, Visitation Rights, Joint, Etc. Access Arrangements/Visitation Schedule? Custody Issues*Are there any ongoing custody or access issues? Yes No Custody Issues*Please describe the custody or access issues indicated above.Emergency Contact InformationIn the case of an emergency BBBSWR would always contact a guardian first, please list someone as a secondary contact, other than the registering guardian.Name* First Last Relationship to the Child* Home Phone*Mobile PhoneOthers Living in the HomeFirst NameLast NameRelationshipAge Add RemovePlease list all adults and other children living in your household, their relationship to the child, and their age (if under 18). Child's InformationPlease describe your child's personality, interests, strengths, and dislikes.*Please identify any specific needs of your child.*Is your child involved with other agencies? If so, which agencies, and for what purpose?*How is your child doing in school?*Does your child get along well with peers and in group settings?*Does your child want a Mentor and to be involved in our programming?* Yes No If applying for the Big Brother or Big Sister program, would your child also be interested in participating in our Big Bunch programming?* Yes No Please read the Big Brothers/Big Sisters Consent Form by clicking on the icon below. I have read and agree to the above Big Bunch informed consent form.* Yes No Please read the Big Brothers/Big Sisters Consent Form by clicking on the icon below. I have read and agree to the above Big Brothers/Big Sisters Program informed consent form.* Yes No Please read the Big Brothers/Big Sisters Consent Form by clicking on the icon below. I have read and agree to the above consent and waiver form.* Yes No Please read the Big Brothers/Big Sisters Media Consent Form by clicking on the icon below. I have read and agree to the above media consent form.* Yes No By checking YES, I acknowledge that I am the parent/guardian of the child for whom I am applying and that I hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by BBBWR. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child.* Yes Parent/Guardian Name* First Last Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Facebook Twitter Google+ LinkedIn
