Full Name of Child
 |
Grade
|
Street Address
|
City
|
State
|
Zip Code
|
Phone
( )- |
Age
|
Birth Date
|
|
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)
|
Parent/Guardian Information |
|
Child Lives with
|
If Other, please specify
|
Name of individual with legal custody of child
|
Marital Status
|
Present Employer
|
Work Address
|
Phone
( ) - |
City
|
State
|
Zip Code
|
|
|
Job Title/Occupation
|
|
Parent or Guardian Email Address
|
|
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The following section should be completed if
child is not living with both parents:
Name(s) and contact information 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
|
|
| Name |
Date of Birth |
| |
|
Relationship to Child
|
|
| Name |
Date of Birth |
| |
|
Relationship to Child
|
|
| 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 Code
|
|
| 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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