Mentee Application

This application will begin the process of applying a child for a Big Friend.  After submitting this application, the parent or guardian will be contacted by a program Match Coordinator.  If this program is appropriate for the service - the next step will be a child interview.  The program will also need to collect information from any professionals; therapists, social workers, teachers, etc, who might help us better serve the child.  An application may be rejected at any time during the process.  It is best that the applied child understand that getting a Big Friend is only a possibility, not a guarantee.

* - Required field
Basic Information
* First Name
* Last Name
Date of Birth
Contact Information
Phone
Email
Demographic Information
* Gender
Ethnicity
* Other Ethnicity
Primary Language
Other Primary Language
Medical Information
Medical Conditions
Medical Conditions Allergies
Medical Conditions Others
Address Information
Address 1
Address 2
City
State
Zip Code
Country
Other Information
Participates in free/reduced lunch
Household Size
Family Structure
* Other Family Structure
Interests
Interests Other
Referral Information
Referral Source
* Other Referral Source
Referral Comments
Referral Date
Reason for Referral
Emergency Contact Information
Primary Emergency Contact
PEC Name
PEC Relationship
PEC Home Phone
PEC Mobile Phone
PEC Work Phone
Primary Emergency Contact Email
Secondary Emergency Contact
SEC Name
SEC Relationship
SEC Mobile Phone
SEC Home Phone
SEC Work Phone
Secondary Emergency Contact Email
Program Questions
Will the applicant's family be remaining in the area for the next 1 year?
Parent's marital status:
If the absent parent sees the child, does he/she know about this application and does the absent parent feel that this is a good idea?
Does the child know the difference between a "good touch" and a "bad touch"?
Please list other adults and children living in the home (names and ages).
What school does youth attend?
What is youth's current grade in school?
How do you think a Big Friend could help this child?
What other agencies are you involved with? Please give names of professionals, agency and phone number.
* Your Name (Person Inquiring)
Relationship to Applicant
Contact Number
Has this child been previously matched through Big Friends Little Friends?