Fill out and submit this form to begin enrolling a child in any of our programs. Please list all contact information, then indicate which program would best fit the child's needs. Follow up this section by answering the questions at the end of the form to help us better serve your child. By clicking submit, this form will be emailed to our office. We will respond to your inquiry as soon as possible. Any information submitted to our agency is confidential.
Child Contact Information
Full Name :
Age :
(Must be between ages 5 and 14)
Date of Birth :
(MM/DD/YYYY)
Living Situation :
Single Parent Home
Both Parents
Other Relative
Other
Zip Code :
School :
Grade Level :
Gender :
Male
Female
Race :
Parent / Guardian Contact Information
Title :
Dr.
Mr.
Mrs.
Ms.
Full Name :
Relation to the Child :
Phone Number :
Is this phone :
Home phone number
Work phone number
Cellular / Portable phone number
E-Mail Address :
Gender :
Male
Female
Race :
Marital Status :
Married
Single
Divorced
Widow(er)
Program Interest
Community-Based Mentoring (CBM): Must be between ages 7 and 14
Bigs in School (BIS): Must be in Elementary School
Additional Information
What is the primary reason for you wanting your child to have a Big Brother or Big Sister?
Please use this text box either to comment on the choices that you have selected or to clarify and provide additional information that will assist in the handling of your particular case.
