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Service Provider Referral Form - Big Brothers Big Sisters of Waterloo Region
  • About Us
    • Contact Us
    • Join the Team
    • Our Board
    • Annual General Reports
    • Our Partners
      • Best Friends of BBBSWR
  • What We Do
    • Our Programs
    • Stories
  • Get Involved
    • Become a Volunteer
    • Enroll a Young Person
    • Ways to Give
  • Events
    • Bowl For Kids’ Sake
    • Gourmet Dinner
    • KingstrEATery
    • JDG Swing Big Golf Classic
    • Taps & Apps
    • Wine Survivor
    • BBBS Month
    • Host an Event
  • Littles and Bigs
    • Activities
    • Community Resources
    • Mental Health Resources
    • Current Opportunities
    • Discount List
    • Scholarship Awards
Donate Volunteer

Service Provider Referral Form

Service Provider Referral Form

"*" indicates required fields

Step 1 of 4

25%

Referral Completed By

Referring Worker Full Name*
Ext.
MM slash DD slash YYYY

Child's Information

Child's Full Name*
Preferred Name
MM slash DD slash YYYY

Primary Caregiver's Information

Primary Caregiver's Full Name*
Ext.
Address*
Does the Primary Caregiver have legal custody of the child?*
Does the Primary Caregiver live with the child?*
Have you spoken with, and is the Primary Caregiver in agreement with this referral?*

Referring Organization's Involvement

To your knowledge, is there anything that would make the child's participation in our programs difficult?*
As an agency, we see guardians as an equal part of a successful match. For that reason, is it your impression that the guardian would be able to:*
Please check all that apply.
By checking this box, the Service Provider confirms that the Guardian had granted full consent to share the above information with Big Brothers Big Sisters of Waterloo Region to assist in the client's intake process.*
Referring Worker's Full Name*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
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To Reach Us
Big Brothers Big Sisters of Waterloo Region
101-135 George Street North Cambridge ON Canada N1S 5C3
Email: info@bbbswr.org Telephone: 5197450180 Contact us Monday: 9:00 AM - 4:30 PM Tuesday: 9:00 AM - 4:30 PM Wednesday: 9:00 AM - 4:30 PM Thursday: 9:00 AM - 4:30 PM Friday: 9:00 AM - 4:30 PM
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© 2025, Big Brothers Big Sisters of Waterloo Region

Charitable Business Number: 131877177RR0001

We recognize the importance of language, and the impact of inclusivity and identity erasure. We acknowledge how our organizational name reinforces the gender binary and fails to honour Trans, non-binary and gender diverse identities. We welcome Mentors and Mentees who are 2SLGBTQ+.  

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