|
Please review the Step to Becoming a Little before completing this application.
If you have difficulty completing this form, please call the office at (505) 434-3388, and we will assist you. There is no fee for our service and your income will not be considered in determining your child's eligibility. |
| Child's Information |
| Name of Child: |
|
| Date of Birth: |
|
| Ethnic Background: |
|
| Gender: |
|
| Religion: |
|
| Speaks Languages: |
English
Spanish
|
| School Attending |
Grade: |
| If your child has any siblings, relatives, or friends in the program, please give their names: |
| |
|
| Program interest: |
Community Program
School Based
|
| |
Other: |
| |
| Parent/Guardian Living with above Child |
| Name: |
|
| Relationship with child: |
|
| Present Marital Status: |
|
| Date of Birth: |
|
| Address: |
|
|
|
| City: |
|
| County: |
|
| State: |
|
| Zip Code: |
|
| Home Phone: |
|
| Cell Phone: |
|
| Email: |
|
| |
| Parent/Guaridan Employment Info |
| What is the yearly income of your family?: |
| |
|
| Employer: |
|
| Title: |
|
| Address: |
|
| Work Phone: |
|
May we call
you at work? |
Yes
No |
| Work Hours: |
Days Off: |
| |
| ABSENT Parent Information (if applicable) |
| Name: |
|
| Present Status: |
|
| Status Date: |
|
| Address: |
|
|
|
| City: |
|
| State: |
|
| Zip Code: |
|
| Home Phone: |
|
| Cell Phone: |
|
| Email: |
|
| What is the primary reason for wanting your son/daughter to have a Big Brother/Big Sister? |
|
| Do you feel your son or daughter has any conditions that will affect him or her in relating to a Big Brother/Big Sister? If yes, briefly explain. |
|
| When and where would it be most convenient to talk with you and your son or daughter so that we can start going to get them matched? |
|
| Additional Comments |
|
|
|
|
