Date

 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

 Date of Birth

Relationship to Child

Education

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.