Child Application Form - Big Brothers Big Sisters of Peel

Child's Name (First, Middle, Last)*

First Middle Last

Birthdate (day/month/yyyy)*

Address*

Street Address City ZIP / Postal Code

Are there plans to move?*

If yes, when? (day/month/yyyy)

Email Address:

Parent/Caregiver's Name*

First Last

Relationship to child*

Telephone: (Residence)

Telephone: (Cell)*

If employed, business name and address*

Business Telephone:

Can we call you at work?

Emergency Contact*

First Last

Emergency Contact: (Telephone)*

Why do you want your child to be involved in our mentoring programs?*

Please describe child's personality, strengths and behaviour*

Child's school, present grade & teacher's name*

What activities does child like doing outside school?*

How did you hear about Big Brothers Big Sisters? (name of worker, teacher, counsellor)*

Does child live with both parents?*

Do all parents support Agency involvement?*

Does child have any limitations that will affect participation in our mentoring programs? (Any medical diagnosis)*

Does your child have allergies? If yes, please list:*

Is child taking any prescribed medications? If yes, please describe fully:*

What is child's Ontario Health Card Number?*

Has the child or family received any help from other agencies, schools, psychiatrists, social workers, CAS etc.? Please list below:*

I certify that the information submitted in this application is true and correct to the best of my knowledge.*