Bellefaire JCB

Bellefaire JCB

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Client Application

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Applicant Information

Full Name of Child
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Grade
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Date
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Street Address
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City
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State
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Zip Code
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Phone 
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Age
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Birth Date
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Sex
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Race
Religion
Child's Email Address
Guardian's Email Address
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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
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 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.

    
 

Bellefaire JCB
Bellefaire JCB
Bellefaire JCB · 22001 Fairmount Boulevard · Shaker Heights, OH 44118
Phone: 216 932-2800 · All Rights Reserved · Copyright ©2008, Bellefaire JCB
a division of Wingspan Care Group
Bellefaire JCB

Download your copy of the 2006-07 Winter Newsletter.Click here.

2006-07 JBBBSA Winter Newsletter

 
 
 
Bellefaire JCB