COMMUNITY-BASED MENTORING PROGRAM - PARENT/GUARDIAN ENROLLMENT FORM

 

Dear Parent: We are excited to offer an opportunity for your child to be paired with an adult volunteer who will “mentor” your child through regular weekly or bi-weekly visits. As part of our community-based program, that volunteer will become a friend to your child and help them with things like setting goals, solving problems, communicating with others and making good decisions. Big and Little “matches” are encouraged to participate in everyday activities such as playing sports, watching movies, washing the car or attending agency-sponsored events together.

 

By completing the enrollment form below and returning it to our office (address below) your child can be matched with a Big Brother or Big Sister. You may also apply online through our agency website: bigmentor.org. If you have any questions, please call our agency Intake Specialist at (210) 225-6322.

 

PARENT INFORMATION

Parent/Guardian Name

 

Address

 

City

 

State

 

Zip Code

 

Home Phone

 

Other Phone

 

Parent/ Guardian Workplace

 

Workplace Phone

 

May we call you at work?

Yes
No

 

E-mail (primary)

 

E-Mail (secondary)

 

Best point of contact

 

Best time to contact

 

CHILD #1 INFORMATION

Child's Name

 

Sex

Male
Female

 

Age

 

Birth Date

 

Ethnicity

 

Child's School

 

Grade

 

CHILD #2 INFORMATION

Child's Name

 

Sex

Male
Female

 

Age

 

Birth Date

 

Ethnicity

 

Child's School

 

Grade

 

CHILD #3 INFORMATION

Child's Name

 

Sex

Male
Female

 

Age

 

Birth Date

 

Ethnicity

 

Child's School

 

Grade

 

CHILD #4 INFORMATION

Child's Name

 

Sex

Male
Female

 

Age

 

Birth Date

 

Ethnicity

 

Child's School

 

Grade

 

Why would you like your child(ren) to have a Big Brother and/or Big Sister?

 

For Statistical Purposes: (Please circle the answers that apply to your family.)

 

Living Situation

Two Parents Single Mother Single Father Relative Group Home

 

Do you receive any Income Assistance?

Yes No

 

Food Stamps?

Yes No

 

Free/Reduced Lunch?

Yes No

 

Family Annual Income Range

Less Than $10,000
$10,000-14,999
$15,000-19,999
$20,000-24,999
$25,000-29,999
$30,000-34,999
$35,000-39,999
$40,000-44,999
$45,000-49,999
$50,000-59,999
$60,000-74,999
$75,000-99,999
$100,000-124,999
$125,000-149,999
$150,000-199,999
$200,000 Or More

 

Does your child have a significant family member (parent, sibling, grandparent, etc.) who is currently

Incarcerated On Probation On Parole? N/A

 

If yes, please describe how this person is related to your child.