Enrollment Application Form

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 Information
Preferred Name
Legal Name*
First Middle Last
Date of Birth*
Date Format: 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*
Previous 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 Information
Health 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*

Other Caregiver Information
Name
First Last
Relationship to the Child
Address
Same as previous

Street Address Address Line 2 City 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 Information
Legal 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 Information
In 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 Phone
Others Living in the Home
First Name Last Name Relationship Age

Please list all adults and other children living in your household, their relationship to the child, and their age (if under 18).

Child's Information
Please 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 consent form.
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

Child's Information

First Name	Last Name	Relationship	Age