a. Date of Inquiry
*
b. Child's First Name:
*
c. Child's Last Name:
*
d. Date of Birth
*
e. Gender
*
Male
Female
Transgendered
Gender Not Represented
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
French
English
Other
r. Preferred Language of Communication
English
French
s. Source of Inquiry
Always Known
Brochure
Business / Corporate
Campus Recruitment
Formerly a Little
Formerly a Big
Information Booth
Newspaper / Written Word
Presentation
Radio
Social Media
Special Event
Television
Website
Word of Mouth
Billboard
t. You are looking for a:
*
Big Brother
Big Sister
Couple's Match (a little matched with a stable couple)
Buddy Up (Little Brother is matched with a Big Sister)
u. Program Type
v. Reason for wanting a Big:
*
w. Does your child want a Big Brother/Big Sister?
*
Yes
No
Haven't Told Them
x. Number of siblings (Brothers & Sisters):
y. Family Status
Single
Married
Dating
Divorced
Widowed
Common Law
Separated
Common Law and Together
N/A
z. Are there circumstances that prevent Littles from getting one to one care from second parents?
Parent Illness
Travel
Significant Stressors
Separated / divorced
Other (Please explain below)
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?
Once a week
Every second week
Once a month
Periodically over the year
Other
zf. Is there current male involvement with the family, i.e. uncle, grandfather, boyfriend?
Yes
No
zh. Please indicate the frequency of contacts:
Once a week
Every second week
Once a month
Periodically over the year
Other
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?