Please fill in all fields marked with a * |
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Child Name (F, M, L)
*
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Birthdate
*
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Ethnicity
*
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Gender
*
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Parent/Guardian Name
*
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Address
*
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City
*
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State
*
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Zip
*
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Home Phone
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Work Phone
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Cell Phone
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Fax
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Email
*
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If you do not have a phone, please give a name and number where messages can be left |
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Name
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Phone Number
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School Information |
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Child's Teacher
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Child's School
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Grade
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Previous School
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Marital Information |
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Marital Status
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Date Divorced
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Date Marriage
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Date Widowed
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Date Separated
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Do you have joint/sole legal c
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Parent Employment Information |
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Present Company Name
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Supervisor Name
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Phone
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Occupation
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May we contact you at work?
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Salary
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Alimony
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Child Support
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Unemployment
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AFDC
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Other
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Non-Custodial Information |
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Non-Custodial Parent
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Non-Custodial Parent Phone
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Non-Custodial Parent Address
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Non-Custodial Parent City
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Non-Custodial Parent State
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Non-Custodial Parent Zip
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Is the parent in contact with
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Siblings |
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Sibling 1 |
Sibling 1 Name
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Sibling 1 Age
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Sibling 1 Relationship
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Sibling 2 |
Sibling 2 Name
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Sibling 2 Age
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Sibling 2 Relationship
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Sibling 3 |
Sibling 3 Name
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Sibling 3 Age
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Sibling 3 Relationship
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Sibling 4 |
Sibling 4 Name
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Sibling 4 Age
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Sibling 4 Relationship
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Why? |
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Please give a brief summary of
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Has your child ever had a Big
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If yes, please list
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Name of Agency
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Agency City
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Agency State
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Agency Zip
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Is your child currently involv
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If yes, list site location
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I would like more information
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Emergency Contact |
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Emergency Contact Name
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Emergency Contact Phone
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Additional Comments
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The information given above is correct and accurate to the best of my knowledge, and I understand that this application constitutes a request to Big Brothers Big Sisters of Central Minnesota to involve my child in their program. I further understand that Big Brothers Big Sisters of Central Minnesota reserves the right to accept or not accept my child based on pre-established criteria. I realize that Big Brothers Big Sisters of Central Minnesota is not obligated to assign, or actively seek to assign, a Big Brother/Big Sister/Big Couple for my child. I understand that I will have the opportunity of learning about a potential volunteer before a match is made, and that I will have the option not to accept the candidate selected by the Big Brothers Big Sisters staff.
**If you haven’t heard from us within 48 hours from submitting your application, there could have been a submission error. Please contact our office at 320-253-1616 to verify that we have received your application. Thank you. ** |
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