A program of Bellefaire Jewish Children's Bureau, 22001 Fairmount Boulevard, Shaker Heights, OH 44118   




Client Application
  
Please complete the fields below. The ' * ' represent required fields.
Applicant Information
 
Full name of Child*:  
 Grade:

Date:

Street Address*:
  
City:
State:
Zip:
Phone:
( ) - 		Age*:
 Date of Birth:
Sex:
 Race:
 Religion:
Child's Email Address:
 Guardian's Email Address:
  We are currently involved in services at Bellefaire JCB    Yes   No
If “yes” what program(s)


 
 
  
Please complete the following information.
Parent/Guardian Information
 
Child Lives with: 


 If Other, please specify:
Name of individual with legal custody of child: 
 		 Marital Status:
Present Employer:

 		  
Work Address:
 Work Phone:
( ) - x
City:
State:
Zip:
Parent's Email Address:
    
The following section should be completed if child is not living with both parents:
 Name(s) of parent(s) who are not living with the child:
Does this parent have contact with the child?

How often?

Is this parent aware of request for service?  Yes   No
 Does this parent have objections to service? Yes   No
 
 
      
Composition of Household
 
Name
Date of Birth
Relationship to Child
 
 
 

Income
 
Is the family receiving income assistance:   Yes   No
If “yes”, indicate type of assistance:   
Approximate monthly family income: $
 
 
Education
 
School Child Attends:  
 		 Present Grade:
School Address:
City:
State:
Zip:
Current marking period grades:  
School conduct:  
 
 
     
Additional Information
 
Please list additional activities in which your child participates: (i.e. camp, temple activities, Boy or Girl Scouts, clubs, etc.)



Does child have a record with the police?  

Yes   No

If "YES", provide background:



Do you have any concerns about your child’s emotional, intellectual or social functioning that a volunteer working with your child should be aware of? 

Yes   No

If “yes” please describe:
 
   
 
AGREEMENT AND CERTIFICATION
 
I certify the information given by me in this application is true in all respects. I allow my child to participate in The Jewish Big Brother Big Sister Association and will support his or her being mentored in a one-to-one capacity, with a minimum of two activities per month. I understand that completion of this application does not imply acceptance into the program.
 
 


 

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