Enrollment Form | Big Brothers Big Sisters of Central Indiana

Step 1. Requirements Step 2. Child Info Step 3. Family Info Step 4. Referral Source Step 5. Parent/Guardian Info

All children in the BBBSCI program are required to live in Marion, Hamilton or Johnson County, be between the ages of 8 and 14, not reside in foster care and participate willingly in the program. Please confirm that the following statements are true for the child. All boxes in this section must be checked to continue.

Step 1. Requirements

The child lives in Marion, Hamilton or Johnson County.

The child is between the ages of 8 and 14.

The child is not in foster care.

I have discussed this opportunity with the child.

Step 1. Requirements Step 2. Child Info Step 3. Family Info Step 4. Referral Source Step 5. Parent/Guardian Info

Step 2. Child Information

Name: (first) * (mi) (last) *

Child’s Date of Birth: * Age: Child must be 8-14 years of age

Gender: Female Male *

Race/Ethnicity

Child’s School: *

Child’s Grade Level:

Average Grade in School: A B C D F

Teacher’s Name:

Describe child’s behavior in school:

Does the child have any known allergies: (i.e. food)

Child’s Personality. Please check all that apply.

Outgoing	Shy	Cheerful	Defiant	Eager to please
Easy going	Rigid	Sullen	Funny	Other:

Choose 3 areas or skills in which the child could use help improving.

Build Confidence	Decision-making skills	Behavior
Relationship with peers	Ability to express feelings	Respect
School Performance	Listening	Patience

Does the child receive services outside of the home? (i.e. counseling, tutoring)

Yes No

If yes, please explain:

Does this child have a family member in prison?

Yes No I don’t know *

How would the child benefit from having a mentor?

Step 1. Requirements Step 2. Child Info Step 3. Family Info Step 4. Referral Source Step 5. Parent/Guardian Info

Step 3. Family Information

Does the family receive free or reduced lunch?

Yes No I don’t know *

Household Annual Income: *

Does the family receive financial assistance?

Yes No I don’t know *

Step 1. Requirements Step 2. Child Info Step 3. Family Info Step 4. Referral Source Step 5. Parent/Guardian Info

Step 4. Referral Source

Name of person making the referral: (first) * (last) *

Agency affiliation of person making the referral:

Phone: *

Email:

Relationship to child: *

How did you hear about us?

Media:	TV Radio Newspaper	Magazine Other website
Web Site:	National BBBS Website Agency BBBSCI Website
	School
	Faith Organization
	Service Organization
	Relative	Therapist/Counselor
	Legal System	Foster Home
	Self	Special Event
	Neighbor/Friend

Step 1. Requirements Step 2. Child Info Step 3. Family Info Step 4. Referral Source Step 5. Parent/Guardian Info

Step 5. Parent/Guardian Information

Is the Parent/Guardian
aware of your referral:

Parent/Guardian Name: (first) * (last) *

Street Address:

City: State: Zip:

Phone:
One phone number is required. (home) (work) (cell) *

Email:

Place of Employment:

Refer a “Little”