ENROL A YOUNG PERSON

Young Person Inquiry Form

To 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@bigbrothersbigsisters

Before you complete the inquiry form, please review the checklist below.*

Please select all that apply.

CHILD/YOUTH INFORMATION

Legal First Name:*

Preferred First Name:

Last Name:*

Gender (Identifies As):*

Pronouns:*

Ethnic Identity:*

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:*

Age:*

School:*

What is the child/youth's school situation?*

Grade:*

Home Address:*

City:*

Postal Code:*

PARENT/GUARDIAN INFORAMTION

Legal First Name:*

Preferred First Name:

Legal Last Name:*

Pronouns:*

Relationship to Child:*

Email*

Primary Phone*

Secondary Phone

Do you live with the young person listed above?*

Is the non-custodial parent /guardian aware of the inquiry to BBBS?*

*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:

Relationship to Child:

Does the secondary caregiver live with the young person listed above?

Others in the home

Name 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 Interests

Child Activity Level:*

Child/Youth Interests:*

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 Survey

Explanation: 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   

2. Child/youth has experienced Parental separation or divorce 

3. Child/youth has been removed from the home by Child Welfare Services OR they have been involved in the home previously 

4. A household/family member has/had a substance abuse problem 

5. A household member has experienced mental illness 

6. A household member as experienced incarceration or has been involved with police 

7. Child/youth has experienced bullying OR has bullied others 

8. Child/youth has often seen or heard violence in the home, neighbourhood or their school 

9. Child/youth has experienced the death or terminal illness of someone close to them 

10. Child/youth arrived in Canada with refugee status 

11. Exposure to financial stress or abuse 

12. Child/youth is exposed to inconsistent caregiver employment  

13. Child/youth is coping or recovering from a mental illness 

Thank 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.

Thank you for your interest in our programs

Young Person Inquiry Form

CHILD/YOUTH INFORMATION

PARENT/GUARDIAN INFORAMTION

SECONDARY CAREGIVER INFORAMTION (if applicable)

Others in the home

Child's Interests

Childhood Experience Survey

Thank you for taking the time to complete this child/youth inquiry form.

CLIENT INTAKE INQUIRIES

Manager, Intake & Partnerships

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