Full Name of Child
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Grade
|
Street Address
 |
City
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State
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Zip Code
 |
Phone
( )-  |
Age
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Birth Date
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Sex
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Race
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Religion
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Child's Email Address
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Guardian's Email Address
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| We are currently involved in services at Bellefaire JCB |
Yes
No
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If yes - what program(s)
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Parent/Guardian Information |
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Child Lives with
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If Other, please specify
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Name of individual with legal custody of child
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Marital Status
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Present Employer
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Work Address
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Phone
( ) - |
City
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State
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Zip Code
|
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Job Title/Occupation
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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?
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| How Often? |
| Is this parent aware of request for service? Yes
No
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| Does this parent have objections to service? Yes
No
|
Composition of Household |
| Name |
Date of Birth |
| |
|
Relationship to Child
|
|
| Name |
Date of Birth |
| |
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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: |
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| School conduct: |
|
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Additional Information |
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Please list additional activities in which your child participates: (i.e. camp, temple activities, Boy or Girl Scouts, clubs, etc.) |
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|
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Does child have a record with the police? Yes
No
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| If YES, provide background: |
| |
| |
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| 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: |
| |
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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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