Child Application Form Child Application Form Child's Name (First, Middle, Last)* First Middle Last Birthdate (day/month/yyyy)* Date Format: DD slash MM slash YYYY Address* Street Address City ZIP / Postal Code Are there plans to move?*YesNoIf yes, when? (day/month/yyyy) Date Format: DD slash MM slash YYYY Email Address: Parent/Caregiver's Name* First Last Relationship to child*MotherFatherGuardianOtherTelephone: (Residence)Telephone: (Cell)*If employed, business name and address*Business Telephone:Can we call you at work?YesNoEmergency 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?*YesNoDo all parents support Agency involvement?*YesNoMaybeDoes 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.*YesNo Facebook Twitter Google+ LinkedIn