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Child App Test

Child/Youth Application Form
Before you complete the application form, please review the checklist below.

I understand that I must be the primary care provider of the child I am referring.I understand that Big Brothers Big Sisters of OxfordCounty is under no obligation to accept my child/provide my child with a MentorI understand that all applicants must be 6 years of age and olderI understand that if accepted, the agency will do everything they can to provide a match, but a one on one match may not always be possible. Agency staff will share other potential opportunities my child may be eligible for e.g. group programming, agency activitiesI understand that my child must be able to communicate and manage self-care independently (toileting, hygiene etc.)I understand that my child must be able to comprehendchild safety messages that will be delivered by BBBS staff through a training program.I understand that my child must not have any behaviours that could put them or others in the program(s) at risk.I understand that my child must be able to build arelationship with an adult Mentor that is positive, healthy, and respectful ofboundaries.I understand that, as the parent/guardian, I will berequired to be aware of how the match is progressing and communicate this to the match coordinator on an ongoing basis.I understand that an inability to maintain this contact with the Match Coordinator(s) could result in the termination of my child’s application and/or the closure of their file / match.
PARENT/GUARDIAN INFORMATION
Parent/Guardian Full Name
If Guardian, please note relationship to child
Address

Address

Street Address Line 2

CityState / Province

Postal Code
Home Phone
Cell Phone
E mail
example@example.com

OTHER PARENT
If there is another parent, who doesn't live in your household but has visitation rights, or partial custody, it is important for us to understand the relationship, supportiveness and schedule of visits when planning programing and/or for safety of our volunteers and staff.
Name
Address
Home Phone
Work Phone
Is the other parent aware of your application for the program?

YesNo
If yes, are they supportive of the involvement? If no, please describe why
If the other parent lives outside your home, please describe current access (i.e. every other weekend, 50/50, etc)
What are your child's reactions to those visists?
Would they allow the child to take part in the program if they day fell on their schedule time?

YesNo
In your view, does your child have a close relationship with the other parent?

FAMILY HISTORY/SITUATION AND RELATIONSHIPS

Other people currently living in your home (please include age and relationship to your child for others in the home, including other children residing in the home).

	Name	Age	Relationship
Person 1
Person 2
Person 3
Person 4

How long has your child lived in your current home?
Has your child ever lived outside of your care?

YesNo
If so, please provide details
How would you describe your relationship with your child?
If other children are in the home, how does your child relate to them?
Does your child tend to have many or just a few friends?

ManyJust a few
Comments
As far as you know, how does your child get along with peers at school?
Does your child tend to play alone or with others?
Please describe your child's personality (moods, temper, maturity level)
Please check the qualities that you feel best describe your child:

FriendlyOutgoingShyWithdrawnLonelyCarefreeBusyOveractive

SOCIAL ACTIVITIES
Is your child interested or active in organized sports, church or group activities?

YesNo
Is your child interested or active in organized sports, church, group activities?
If yes, please list
Please indicate what hobbies, if any, your child currently enjoys.
Briefly describe your child's weekly schedule of activities.

ABOUT A MENTOR
How do you feel your child would benefit most from a mentor?
Describe the type of Mentor you would like for your child
What types of activities do you think your child would like to do with a mentor?
Is there any information you would like to add to this application that will help us to serve your child's needs better?

CONFIDENTIALITY
Just as we have to share information with you about the mentor we select for your child, we need to share information with the volunteer about you and your child. Is there anything in this application you do not want share with a volunteer?

YesNo
If yes, please clearly state what you do not want shared
Your Name
Your Signature

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MonthDayYear
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The answers you have given will help us to do our best for your child. Please be sure to advise us of any changes in your home situation, such as address changes, relationship changes, etc.
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Child App Test

Child/Youth Application Form

PARENT/GUARDIAN INFORMATION

Medical History