Little Brother/Little Sister Application
(to be filled in by Parent/Guardian)
Child’s Name______
Date of Birth______Age _____ Place of Birth______
Address ______
Postal Code ______
Home Phone ______E-mail ______
Languages Spoken ______
Child’s Doctor ______Phone ______
Health Card #______
Emergency Contact ______Phone ______
Relationship to Child ______
Parent/Guardian
Parent/Guardian Name: ______If Guardian, please note relationship to child: ______
Date of Birth: ______
Marital Status: ______
Are you employed? (can we call you at work? Yes No)
Where?______Work Phone ______
Are you unemployed?
EI? Social Assistance? Disability?
Other ______
Are you a student? Where? ______Phone ______
Are you or your child involved with any other community agency? Yes No
Agency Name: ______Phone: ______
Staff: ______
Other Parent
Name:
Address: ______
Home Phone: ______Work Phone:
Relationship with Child: ______
What type of relationship does your child have with the other parent? ______
If you are a single parent with custody, what are the visiting rights of the other parent? Does he/she use these rights? What are the access arrangements?
______
______
What are your child’s reactions to those visits? ______
How are you with those visits?
Please describe the kinds of activities they do together.
In your view, does your child have a close relationship with the other parent?
Is the other parent aware of your application for the program? Yes No
If yes, what is his/her attitude? If no, why not?
______
Other parent’s marital status
Family History/Situation
Other people at home (please include age, gender, and relationship) (including children)
Name / Age / Gender / RelationshipHow long has your child lived in your current home? ______
Has your child ever lived outside of your home? Yes No
(If so, please provide details) ______
______
Does anything prevent your child from fully participating in the program? Yes No
Please explain: ______
______
Medical History
Does your child have any medical problems, conditions or allergies? Yes No
If yes, please explain: ______
Is your child on any medication? Yes No
If yes, please explain: ______
Has your child ever seen or is your child now seeing a psychologist, social worker, therapist, counsellor etc? Yes No
If yes, please explain (include approximate dates, contact information of worker): ______
How physically fit is your child? ______
Do you think your child has any emotional difficulties? Yes No
If yes, please explain: ______
______
Relationships
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?
Are they mostly boys, girls, or both?
Comments: ______
______
As far as you know, how does your child get along well 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:
Friendly Outgoing Shy Withdrawn Lonely
Carefree Busy Overactive
How do you discipline your child? ______
School
School: ______
Address: ______
______
Phone: ______
Grade: Teacher: ______
Does your child seem interested in school? Yes No
Has your child ever been involved in a special education program? Yes No If yes, please comment: ______
Has your child ever failed a grade? Yes No
If yes, which one(s)? ______
How does your child generally get along with the teacher? ______
How is your child doing in school? ______
Do you think your child is doing as well as he/she can in school? Yes No
If no, please explain: ___
Does your child get in trouble at school? Yes No
If yes, is it often? Occasionally? Seldom?
Social Activities
Is your child interested or active in sports, church, group activities? Yes No
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 Big Brother/Big Sister
Is your child aware of your application for a Big Brother/Big Sister? Yes No
If yes, what was the reaction? ______
How do you feel your child would benefit most from a Big Brother or Big Sister? ______
Describe the type of Big Brother/Big Sister you would like for your child ______
What types of activities do you think your child would like to do with a Big Brother/Big Sister? ______
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 Big Brother/Big Sister we select for your child, we need to share information with the volunteer about you and your child. Is there anything here that you do not want shared with a volunteer? Yes No
If yes, please clearly state what you do not want shared: ______
______
______
Your Name Your Signature
______
Date
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.
Big Brothers Big Sisters Association of Wood Buffalo
AGREEMENT: PARENT
1. Orientation:
I understand and am in agreement with the objectives of Big Brothers Big Sisters Association of Wood Buffalo, through the orientation I have attended. I have received information on the following:
__ philosophy and program of the Agency
__ criteria for volunteer acceptability
__ an overview of the screening and matching policy
__ an explanation of the Agency’s expectations of volunteers, parents and children
__ an explanation of the Agency’s responsibility to children, parents and volunteers
__ an explanation of the training for the prevention of child abuse (Child Safety Program).
2. Child Safety Program:
I am aware that Big Brothers Big Sisters Association of Wood Buffalo is of the opinion that sexual abuse prevention education is an effective preventative safeguard.
I am aware that it is the policy of Big Brothers and Sisters of Canada* to require all Littles and their parents to attend a Child Safety Program, organized by the local Big Brothers/Big Sisters organization. I also understand that all my children are welcome to attend.
I agree that my child and I will attend the Child Safety Program, when scheduled.
Signature:
Witness:
Date:
CHILD INTEREST FINDER SHEET
The following 3 pages (7-9) are for the Little Brother/Sister to fill out
FIRST NAME: ______AGE: ______
**PLACE AN X BESIDE YOUR ANSWER: CIRCLE YOUR 5 FAVORITES AFTERWARDS
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Want to
Activity Like Dislike Learn
1. Animals
2. Archery
3. Art
4. Baking
5. Baseball
6. Basketball
7. Bicycling
8. Board Games
9. Boating
10. Bowling
11. Camping
12. Cards
13. Carpentry
14. Collecting
15. Computers
16. Cooking
17. Crafts
18. Dancing
19. Downhill Skiing
20. Fishing
21. Football
22. Gardening
23. Golf
24. Hiking
25. Hockey
Other: ______
Want to
Activity Like Dislike Learn
26. Hunting
27. Ice Skating
28. Jogging
29. Martial Arts
30. Mechanics
31. Models
32. Movies
33. Music
34. Photography
35. Pool
36. Quadding
37. Reading
38. Rollerblading
39. Science
40. Snowmobiling
41. Soccer
42. Swimming
43. Table Tennis
44. Tennis
45. Video Games
46. Volleyball
47. Walks in Park
48. Water Skiing
49. Woodworking
50. X-Country Skiing
August 2002 Page 11 of 11
August 2002 Page 11 of 11
THE “ME” SHEET
COMPLETE THESE SENTENCES AS QUICKLY AS YOU CAN
PLEASE DO NOT SKIP ANY OF THEM
1. My School:
2. I am proud of:
3. I like
4. My dreams
5. My mother
6. My brother(s)
7. My sister(s)
8. I am sorry
9. My father
10. It makes me angry
11. My good friend is
12. Other kid’s my age
13. Boys
14. Girls
15. I worry most
16. My mother treats me
17. My father treats me
18. I am happiest when
19. I hope
20. Policemen(women)
21. Sometimes people
22. Black
23. White
24. Adults
25. Mud
THANK YOU!
We look forward to meeting you ☺
MORE “ME”
1. Do you want a Big Brother/Sister?
2. What kind of person would you want as a Big Brother/Sister:
3. Your Big Brother/Sister will want you to think of things to do together. Would you be willing to do this?
4. What outside activities do you like the most?
5. Do you belong to any group or team (e.g. sports, scouting) If yes, please list below.
6. What quiet activities do you like most?
7. What things have you never done before that you would like to try with your Big Brother/Sister?
8. Are there any activities that you do not like to do? If yes, what are they?
9. When you are not in school, what do you spend most of your time doing?
10. Choose 5 words to describe yourself
11. What do you like about yourself?
12. What do you not like about yourself?
13. Which do you do most?
Play Alone ______With A Friend ______With A Group Of Friends ______
THANK YOU!
We look forward to meeting you ☺
MEDIA CONSENT FORM – CHILD PERMISSION
I, ______, hereby consent to Big Brothers Big Sisters Association of Wood Buffalo to use any photographs, audio and/or video recordings of ______as taken or produced by media personnel and/or Association Staff for the purpose of publicizing and promoting the work of the Association. This includes radio, television, newspapers, newsletters, and the internet. This means I authorize my pictures to be uploaded onto the internet and the Big Brothers Big Sisters Website and waive all claims I have against the agency for any issue arising from said publication. I further waive any claim which I may have against Big Brothers Big Sisters Association of Wood Buffalo arising from the use of such photographs, audio and/or video recordings of myself in any other way, as afore said.
This consent and waiver shall remain in effect for the duration of my involvement with Big Brothers Big Sisters Association of Wood Buffalo unless otherwise revoked.
______
Date Signature of Parent/Guardian
______
Date Signature of Child (if over 12 years of age)
______
Date Signature of Witness
************************************************************************
NOTE: Confidentiality concern
If you do not want your picture to be used, please check here:
Name: ______
Date: ______
Note: It is your responsibility to notify the office if the status of this consent changes
August 2002 Page 11 of 11