BIG BROTHERS BIG SISTERS OF LUBBOCK, INC.

 

CHILD APPLICATION                                                                                                              (PLEASE ATTACH RECENT PHOTO)

(TO BE COMPLETED BY CHILD’S PARENT/GUARDIAN)

I. CHILD INFORMATION

CHILD’S FULL NAME___________ __________________________ NICKNAME _______________

DATE OF BIRTH ______________________ RACE _____________________ SEX ____________________

ADDRESS__________________________________________________________________________________

CITY ______________________________ STATE ___________________ ZIP _________________________

CHILD’S SCHOOL ____________________________________ GRADE _____________________________

TEACHER ________________________________________ SCHOOL PHONE _______________________

II. PARENTAL/GUARDIAN INFORMATION

PARENT/GUARDIAN NAME ________________________________________________________________

HOME PHONE _____________________________________ WORK PHONE ________________________

EMAIL ADDRESS (IF APPLICABLE) ________________________________________________________

RELIGION, IF ACTIVE _____________________________________________________________________

EMPLOYER __________________________________________________ WORK HOURS ______________

OCCUPATION ____________________________________________ MAY WE CALL @ WORK _________

HIGHEST LEVEL OF EDUCATION _________________________ HIGH SCHOOL GRAD? _________

CURRENT MARITAL STATUS: SINGLE – MARRIED – SEPARATED - WIDOWED

IF DIVORCED, WHO IS LEGAL GUARDIAN OF THE CHILD? ________________________________

III. ABSENT PARENT INFORMATION

PARENT NOT LIVING IN THE HOME: NAME ___________________________________________

ADDRESS ________________________________________

PHONE __________________________________________

PRESENT EMPLOYER ____________________________

MARITAL STATUS ________________________________

IS ABSENT PARENT AWARE OF CHILD’S INVOLVEMENT WITH BIG BROTHERS BIG

SISTERS? _________ YES __________ NO

 

  1. LIST ALL PEOPLE WHO LIVE IN THE HOUSE WITH THE CHILD. (INCLUDE YOURSELF.)

    NAME SEX BIRTH DATE RELATIONSHIP

    1.___________________________________________________________________________________________

    2. __________________________________________________________________________________________

    3.___________________________________________________________________________________________

    (PLEASE LIST ADDITIONAL ON BACK)

  2. EMERGENCY INFORMATION (OTHER THAN PARENT/GUARDIAN)

    IN CASE OF EMERGENCY, PLEASE CONTACT: (LOCAL PREFERRED)

    NAME: ________________________________________________________ RELATIONSHIP ____________

    ADDRESS: _________________________________________________________________________________

    HOME PHONE: _________________________________________ WORK PHONE: ___________________

     

  3. PLEASE CHECK OUT ALL THAT APPLY TO YOUR CHILD. YOUR HONEST

    ANSWERS WILL ENABLE YOUR CASEMANAGER TO BETTER MATCH YOUR CHILD.

    HAS OWN ROOM _______ WITHDRAWN _______

    SHARES ROOM W/ SIBLING _______ MAKES FRIENDS EASILY _______

    SHARES ROOM _______ MOST FRIENDS ARE BOYS _______

    EMOTIONAL PROBLEMS _______ MOST FRIENDS ARE GIRLS _______

    SLEEPS WELL _______ ACCEPTS RESPONSIBILITY _______

    HAS NIGHTMARES _______ HYPERACTIVE _______

    USES BAD LANGUAGE _______ DEPENDENT _______

    HAS A SMART MOUTH _______ INDEPENDENT _______

    TEMPER TANTRUMS _______ HAS BEEN PHYSICALLY ABUSED _______

    RECEIVES ALLOWANCE _______ HAS BEEN SEXUALLY ABUSED _______

    HAS OR DOES DRUGS _______ HAS BEEN EMOTIONALLY ABUSED _______

    HAS OR DOES ALCOHOL _______ HAS HIGH SELF-ESTEEM _______

    HAS CONTACT W/ ALCOHOL USERS _______ HAS LOW SELF-ESTEEM _______

    HAS ALLERGIES _______ HAS AGGRESSIVE BEHAVIOR _______

    WETS THE BED _______ TRUANCY PROBLEMS _______

    HAS A CHRONIC ILLNESS _______ GANG INVOLVEMENT _______

    IS ON REGULAR MEDICATION _______ CONFLICT W/ PARENT _______

    PHYSICAL DISABILITY _______ SEXUALLY ACTIVE _______

    MENTAL DISABILITY _______ INVOLVED W/ LAW _______

    IS SHY _______ BEHAVIORAL PROBLEMS _______

    IS OUTGOING _______ HAS A LEARNING DISORDER _______

    FOLLOWER _______ GOOD RELATIONS W/ PEERS _______

    LEADER _______ BAD RELATIONS W/ PEERS _______

     

 

  1. THIS PART IS FOR YOUR CHILD TO FILL OUT. YOU MAY HELP IF NEEDED.

NAME: __________________________________________________ AGE _____________________________

1. WOULD YOU LIKE TO HAVE A BIG BROTHER OR SISTER? _______YES _______ NO

  1. WHAT KINDS OF THINGS WOULD YOU LIKE TO DO WITH A BIG BROTHER OR SISTER?

_________________________________________________________________________________________

3. WHOSE IDEA WAS IT FOR YOU TO GET A BIG BROTHER OR SISTER? ___________________

_________________________________________________________________________________________

4. I WANT MY BIG BROTHER OR SISTER TO _______________________________________________

__________________________________________________________________________________________

  1. WHAT DO YOU THINK IS THE BEST THING ABOUT YOU? ______________________________

_____________________________________________________________________________

6. WHAT DO YOU THINK IS THE WORST THING ABOUT YOU? _____________________________

__________________________________________________________________________________________

7. IF I HAD A HUNDRED DOLLARS, I WOULD ______________________________________________

__________________________________________________________________________________________

8. SECRETLY I WISH ______________________________________________________________________

__________________________________________________________________________________________

9. I GET ANGRY WHEN ____________________________________________________________________

__________________________________________________________________________________________

  1. WHEN I HAVE KIDS THEY WON’T HAVE TO ____________________________________________

    ________________________________________________________________________________________

     

  2. I AM HURT MOST EASILY WHEN ______________________________________________________

________________________________________________________________________________________

12. I FEEL HAPPIEST OF ALL WHEN _______________________________________________________

_________________________________________________________________________________________

13. THE FUNNIEST THING I EVER SAW WAS _______________________________________________

_________________________________________________________________________________________

  1. THE BEST THING ABOUT GETTING A BIG BROTHER OR SISTER IS ____________________

_________________________________________________________________________________________

  1. In determining whether a child may be considered for a match and what information shall be communicated to each party involved in any perspective match regarding the others, due consideration is given to those past and present factors of health, personality and behavior of each individual and/or family members which the professional staff of the agency deem under the circumstances may have a significant effect upon the relationship and which if revealed at a later dated, might affect it adversely. Information, which is considered relevant will be shared. This shall include child’s age, race, and religious preference, a description of child’s home environment lifestyle and family situation, a summary of child’s hobbies and interests and evaluation of the child’s needs as related to program participation.

I understand that the Big Brothers Big Sisters agency is not obligated to assign, or actively seek to assign a volunteer to any child. I further understand that the agency makes no warrantee, guarantee, or other commitment either stated or implied as impact of a match upon any of the parties involved whether emotional, psychological, spiritual, or physical, other than the normal guarantee of any individual that the best judgement and concern will be applied in dealing with the human personality. In recognition thereof, I hereby agree to hold free of liability the BBBS agencies, both local and national and all agents and representatives thereof in the event of any unfortunate results of developments occurring as a part of their efforts on my behalf.

I grant permission to any school to allow my child to meet with a worker from BBBS of Lubbock and to release any information, regarding myself or my child(ren) to BBBS of Lubbock. This release also applies to any physician, hospital, welfare or social agency.

I authorize the BBBS volunteer assigned to my child(ren) or any director or staff member of BBBS to obtain necessary medical and/or surgical treatment in case of illness, accident or any emergency situation that may arise. These medical services are to be performed by: ___________________________________ or in his/her absence, any licensed medical doctor. I further state that I will not hold the BBBS volunteer, or any director or staff member liable in case of illness, accident or emergency situation.

 

Signature ______________________________________ Date ________________________________

 

 

 

 

I understand that as a client/parent of Big Brothers Big Sisters of Lubbock, Inc., the agency and United Way are not responsible for any and all accidents concerning my child during any related Big Brothers Big Sisters activity.

By signing this waiver, I understand that Big Brothers Big Sisters does not insure my child as a passenger in the vehicle of any assigned volunteer and/or staff.

 

 

 

 

 

________________________________________

(Parent/Guardian Signature)

 

NOTE: Each volunteer and/or staff member/volunteer is required by the agency to have at least minimal state insurance required by law.