Please complete all fields to ensure we will be able to process your request in a timely manner. 

First Name*
Last Name*
Date of Birth (mm/dd/yyyy)*
Primary Caregiver Name*
Program - Halifax
Home Phone
Mobile Phone
Business Phone
Ext (Business)
Address: Street*
Address: City*
Address: Postal Code*
Referring Worker (if applicable)
Referring Worker Email

Big Brothers Big Sisters agencies in Canada use a centralized online case file system. If you have been involved in the past with another Big Brothers Big Sisters agency in Canada, the information you submit in this form will be transmitted and shared with both the agency you are applying to, along with the agency you previously were involved with. If you do not want your information shared with the previous agency you had contact with, please contact Denise Legere (

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Please fill in todays date:*
Lead Source