a. Date of Inquiry*
 
 
b. Child's First Name:*
 
 
c. Child's Last Name:*
 
 
d. Date of Birth*
 
 
e. Gender*
 
 
 
f. Street Address:*
 
 
g. City:*
 
 
h. Province:*
 
 
i. Postal Code:*
 
 
j. Country
 
 
 
k. Parent/Guardian's Name (First & Last):*
 
 
 
l. Other Parent/Caregiver's Name (First & Last)::
 
 
 
m. Home phone:*
 
 
n. Mobile Phone*
 
 
 
o. E-mail*
 
 
p. Alternate E-mail
 
 
 
q. Language(s) Spoken
 
 
r. Preferred Language of Communication
 
 
s. Source of Inquiry
 
 
t. You are looking for a:*
 
 
u. Program Type
 
 
v. Reason for wanting a Big:*
 
 
w. Does your child want a Big Brother/Big Sister?*
 
 
x. Number of siblings (Brothers & Sisters):
 
 
 
y. Family Status
 
 
z. Are there circumstances that prevent Littles from getting one to one care from second parents?
 
 
za. For a two parent household or for shared custody, are both parents agreeing to getting a Big Brother/Sister?
 
Yes
No
 
 
 
Male Involvement
 
 

to be completed for LITTLE BROTHER applicants only

 
 
zb. Father's Name:
 
 
zc. Father's Location (Address):
 
 
 
zd. Does the Father have visiting rights?
 
Yes
No
 
 
ze. If "Yes" how often does he exercise this right?
 
 
 
zf. Is there current male involvement with the family, i.e. uncle, grandfather, boyfriend?
 
Yes
No
 
zh. Please indicate the frequency of contacts:
 
 
 
 
 
Medical History
 
zi. Does your child have any medical conditions we should be aware of?
 
Yes
No
 
 
zj. Is your children taking any medication?
 
Yes
No
 
 
zk. Has your child been diagnosed with any special needs?
 
Yes
No
 
 
zl. Can your children communicate through speech?
 
Yes
No
 
 
zm. Does your child understand and answer questions when spoken to?
 
Yes
No
 
 
zn. Are there behaviour challenges at school?
 
Yes
No
 
 
zo. Are there behaviour challenges at home?
 
Yes
No
 
 
zp. What are the behaviours at home and school? (Must be manageable without behavioural intervention training):
 
 
 
 
Sensory/Stress Response
 
The Volunteer would need to be able to anticipate problematic situations in advance (i.e. crowds, loud noises)

  
zq. What sensory responses does your child react to?
 
 
 
zr. What is your child's response/reaction to this?
 
 
 
zs. Is there a flight risk (bolting, running away from home or from school)?
 
Yes
No
 
 
zt. If "Yes" please explain.
 
 
zu. What special skills would a volunteer require in order to spend time with your child?