Client Inquiry – Community Programs Young Person Inquiry FormTo begin the enrollment process for a young person in the Community-Based Matching Programs (Big Brothers/Big Sisters), please complete the fields below. Please be advised that the enrollment process also includes an application, family interview and a training session. *Note: For any group-based program inquiries, please contact our Group Program Director, Marika.Mennaman@bigbrothersbigsistersBefore you complete the inquiry 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 Grand Erie, Halton and Hamilton is under no obligation to accept my child/provide my child with a Mentor. I understand that all applicants must be between the ages of 6 to 14 years old. I understand that it may take up to two years before my child to be matched. I 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 comprehend child safety messages that will be delivered 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 a relationship with an adult Mentor that is positive, healthy, and respectful of boundaries. I understand that, as the parent/guardian, I will be required to be aware of how the match is progressing and communicate this to the Case Manager on a regular basis. I understand that an inability to maintain this contact with the Case Manager(s) could result in the termination of my child’s application and/or the closure of their file / match. Please select all that apply.CHILD/YOUTH INFORMATIONLegal First Name:* Preferred First Name: Last Name:* Gender (Identifies As):*FemaleMaleNon-binaryGender NeutralGender FluidOtherPrefer not to sayPronouns:*he/himshe/herthey/theme/ey/em(f)ae/(f)aerper/perve/verxe/xemOtherEthnic Identity:* American African Asian Canadian French Canadian Central American Chinese First Nations Inuit Metis Middle Eastern South American Southeast Asian Pacific Islands Unsure Other Prefer not to say Please select all that apply.If you selected other for Ethnic Identity, please indicate your response here: Community Identity:* Black Caucasian Indian LBGTQIA2S+ Person of Colour BIPOC Other Prefer not to say Please select all that apply.If you selected other for Community Identity, please indicate your response here: Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:*6 years of age7 years of age8 years of age9 years of age10 years of age11 years of age12 years of age13 years of age14 years of age15 years of age16 years of age17 years of age18 years of ageOtherSchool:* What is the child/youth's school situation?*Public SchoolCatholic SchoolHome SchooledPrivate SchoolOnline SchoolAlternate SchoolOtherPrefer not to sayGrade:* Home Address:* City:* Postal Code:* PARENT/GUARDIAN INFORAMTIONLegal First Name:* Preferred First Name: Legal Last Name:* Pronouns:*he/himshe/herthey/theme/ey/em(f)ae/(f)aerper/perve/verxe/xemOtherRelationship to Child:* Email* Primary Phone*Secondary PhoneDo you live with the young person listed above?*YesNoThird ChoiceIs the non-custodial parent /guardian aware of the inquiry to BBBS?*Not ApplicableYesNo*Note – it is important any other caregivers that have regular access to the child/youth be aware of and supportive of the program. SECONDARY CAREGIVER INFORAMTION (if applicable)Legal First Name: Preferred First Name: Legal Last Name: Pronouns:he/himshe/herthey/theme/ey/em(f)ae/(f)aerper/perve/verxe/xemOtherRelationship to Child: Does the secondary caregiver live with the young person listed above?YesNoThird ChoiceOthers in the homeName 1 Relationship to Child 1 Name 2 Relationship to Child 2 Name 3 Relationship to Child 3 Additional notes for others in the home, if applicable: Child's InterestsChild Activity Level:*Highly ActiveActiveSomewhat ActiveNot Active at allChild/Youth Interests:* Animals Cooking Educational Activities Music Talking Arts & Crafts Computers Festivals & Local Events Outdoor Activities Video Games Building Lego Cultural Activities Indoor Activities Reading/Books Board Games/Cards Dance Movies/TV Sports Please select all that apply.List the child/youth's top three interests:* List three interests/activities the child/youth would like to try:* How do you feel the child/youth will benefit from a mentor?*Childhood Experience SurveyExplanation: The following information can assist the agency in making the best match to suit your child's needs, as well as to ensure we are providing the most appropriate services to the young people in our communities. Please only share what you are comfortable sharing. Answering these are not required for your child to receive service from the agency. 1. Child/youth is experiencing social isolation Please selectPrefer not to answerYesNo2. Child/youth has experienced Parental separation or divorce Please selectPrefer not to answerYesNo3. Child/youth has been removed from the home by Child Welfare Services OR they have been involved in the home previously Please selectPrefer not to answerYesNo4. A household/family member has/had a substance abuse problem Please selectPrefer not to answerYesNo5. A household member has experienced mental illness Please selectPrefer not to answerYesNo6. A household member as experienced incarceration or has been involved with police Please selectPrefer not to answerYesNo7. Child/youth has experienced bullying OR has bullied others Please selectPrefer not to answerYesNo8. Child/youth has often seen or heard violence in the home, neighbourhood or their school Please selectPrefer not to answerYesNo9. Child/youth has experienced the death or terminal illness of someone close to them Please selectPrefer not to answerYesNo10. Child/youth arrived in Canada with refugee status Please selectPrefer not to answerYesNo11. Exposure to financial stress or abuse Please selectPrefer not to answerYesNo12. Child/youth is exposed to inconsistent caregiver employment Please selectPrefer not to answerYesNo13. Child/youth is coping or recovering from a mental illness Please selectPrefer not to answerYesNoThank you for taking the time to complete this child/youth inquiry form.The information you provided helps us understand how the young person you are referring may be supported. Please note that Big Brothers Big Sisters of Grand Erie, Halton and Hamilton respects the privacy of our clients and families - The information you have provided will remain confidential. Our intake team will connect with you when we are ready to proceed with the next steps of enrollment.