Program of Interest
 
 
 
 
 
 
 
A - YOUR CHILD
 
 
 
 
 
aa-Chil'd Given Name*
 
 
ac-Date of Birth*
 
 
ad-Child's Age
 
 
ab-Child's Last Name*
 
 
ae-Gender Preference*
 
 
 
af-Address (apt, number and street)*
 
 
ag-Address 1 : City*
 
 
ah-Province/Territory*
 
 
ai-Postal Code*
 
 
aj-Parent Email Address*
 
 
 
ak-Home Phone*
 
 
al-Alternate Phone*
 
 
 
am-Preferred Language of Communication*
 
 
 
 
an-Additional Languages Spoken
 
 
 
 
ao-Emergency Contact
 
 
ap-Relationship
 
 
aq-Phone
 
 
ar-Born in Canada
 
 
as-If no, what is your country of origin?
 
 
at-Newcomer Status
 
 
au-How long have you been in Canada?
 
 
av-Ethnic Identity
 
 
aw-School
 
 
ax-Grade
 
 
 
 
 
Other
 
 
 
 
 
Does your child have any medical conditions we should be aware of?*
 
Yes
No
 
 
If yes, please explain:
 
 
 
Is your children taking any medication?*
 
Yes
No
 
 
If yes, please specify
 
 
 
Has your child been diagnosed with any special needs?*
 
Yes
No
 
 
If yes, please specify
 
 
 
Does your child have a mental health issue?*
 
Yes
No
 
 
If yes, please specify
 
 
 
Have you discussed the Big Brothers or Big Sisters program with your child?*
 
Yes
No
 
 
If so, what were their comments?
 
 
 
 
 
B - CAREGIVER(S) INFORMATION
 
 
 
 
Primary Caregiver
 
 
 
 
ba-Full Name*
 
 
bb-Mobile Phone*
 
 
bc-Work Phone
 
 
bd-Relationship to Child*
 
 
 
 
be-Do you have any other children involved with this agency? (Matched, Waiting List, In School Mentoring/Go Girls!/Game On! Program?*
 
Yes
No
 
 
bf-If yes, please list their names:
 
 
 
 
 
 
Other Caregiver
 
 
bg-Full Name*
 
 
bh-Mobile Phone*
 
 
bi-Work Phone
 
 
bj-Relationship to Child*
 
 
 
 
 
 
C - PROFESSIONAL INVOLVEMENT
 
 
ca-Have any of the following school services been involved with your child?
 
 
 
cb-If yes, please state the details (names, dates, etc.):
 
 
 
cc-Are there social service agencies involved with your family? (i.e. - Hospitals, Children's Aid Society, Youth Services Bureau, etc.)
 
 
 
cd-If yes, please state details: (names, dates, etc.) With your consent Big Brothers Big Sisters Ottawa would like to contact the community agencies involved with your child.
 
 
ce-Name and address of agency
 
 
 
cf-Contact Person and Telephone Number
 
 
 
cg-Dates of Involvement
 
 
 
 
 
D - MALE INVOLVEMENT (to be completed for Little Brother applicants only)
 
 
 
 
da-Father's Full Name:
 
 
 
 
db-Does the Father have visiting rights?
 
Yes
No
 
 
de-If "Yes" how often does he exercise this right?
 
 
 
df-How old was your son when separation/death occurred?
 
 
 
dg-What is your son's reaction to the absence of his father?
 
 
 
dh-Is there presently male involvement with the family, i.e. uncle, grandfather, boyfriend?
 
Yes
No
 
 
di-If yes, please identify his relationship to you:
 
 
 
dj-Please indicate the frequency of contacts:
 
 
 
 
dk-By selecting this box and entering my full name and clicking Submit, I agree that the statements made in this application are true and correct and have been given freely.*
 
 
 
 
dl-Full name*
 
 
dm-Date*