Application Form

Full Name of Child *

Grade *

Street Address: *

City: *

State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *

Zip Code: *

Phone: *

Age: *

Birth Date: *

Sex:

Race: *

Religion:

Child's Email Address:

Guardian's Email Address: *

We are currently involved in services at Bellefaire JCB Yes No

If yes - what program(s)

Child Lives With: Select One Mother Father Relative Foster Care Other

If other, please specify

Name of individual with legal custody of child:

Marital Status: Select One Single Never Married Married Divorced Widowed Remarried Separated

Present Employer:

Work Address:

Phone:

City:

State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Job Title/Occupation:

Parent or Guardian Email Address:

Name(s) and contact information of parent(s) who are not living with the child:

Does this parent have contact with the child? Select One Yes No Occasionally

How Often?

Is this parent aware of request of service? Yes No

Does this parent have objections to service? Yes No

Is the family receiving income assistance? Yes No

If yes?, indicate type of assistance:

Approximate monthly family income:

School Child Attends:

Present Grade:

School Address:

City:

State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zipcode:

Current marking period grades: Select One Excellent Good Fair Poor

School Conduct: Select One Excellent Good Fair Poor

Please list additional activities in which your child participates: (i.e. camp, temple activities, Boy or Girl Scouts, clubs, etc.)

Does child have a good record with police? Yes No

If YES, provide background:

Do you have any concerns about your child(s) emotional, intellectual or social functioning that a volunteer working with your child should be aware of? Yes No

If yes, please describe:

I certify the information given by me in this application is true in all respects. I allow my child to participate in The Jewish Big Brother Big Sister Association and will support his or her being mentored in a one-to-one capacity, with a minimum of two per month. I understand that completion of this application does not imply acceptance into the program. *