Little Brother/Little Sister Application
(to be filled in by Parent/Guardian)
Child’s Name_______________________________________
Date of Birth_________________
Age _____
Place of Birth___________________
Address _________________________________________________________________
Postal Code ________________
Home Phone ______________________
E-mail ______________________________
Languages Spoken _________________________________________________________
Child’s Doctor ______________________________________ Phone _______________
Health Card #______________________________________
Emergency Contact __________________________________Phone ________________
Relationship to Child ________________________________________
Parent/Guardian
Parent/Guardian Name: ___________________________________________________
If Guardian, please note relationship to child: ____________________________
Date of Birth: _____________________________
Marital Status: _____________________________
Are you employed? (can we call you at work?
Yes
No)
Where?___________________________ Work Phone __________________
Are you unemployed?
EI?
Social Assistance?
Disability?
Other ___________________________________
Are you a student?
Where? _________________________ Phone _______________
Are you or your child involved with any other community agency?
Yes
Agency Name:
____________
__________
Phone:
No
Staff: _____________________________________
August 2002
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Other Parent
Name:
Address:
______________________________
Home Phone: ___________________________ Work Phone:
Relationship with Child: ____________________________________________________
What type of relationship does your child have with the other parent?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If you are a single parent with custody, what are the visiting rights of the other parent? Does
he/she use these rights? What are the access arrangements?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are your child’s reactions to those visits?
______
How are you with those visits?
Please describe the kinds of activities they do together.
In your view, does your child have a close relationship with the other parent?
Is the other parent aware of your application for the program?
Yes
No
If yes, what is his/her attitude? If no, why not?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other parent’s marital status
August 2002
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Family History/Situation
Other people at home (please include age, gender, and relationship) (including children)
Name
Age Gender
Relationship
How long has your child lived in your current home? ____________
Has your child ever lived outside of your home?
Yes
No
(If so, please provide details) ________________________________________________
________________________________________________________________________
________________________________________________________________________
Does anything prevent your child from fully participating in the program?
Yes
No
Please explain: ___________________________________________________________
_______________________________________________________________________
Medical History
Does your child have any medical problems, conditions or allergies?
Yes
No
If yes, please explain: ______________________________________________________
Is your child on any medication?
Yes
No
If yes, please explain: ______________________________________________________
Has your child ever seen or is your child now seeing a psychologist, social worker, therapist,
counsellor etc?
Yes
No
If yes, please explain (include approximate dates, contact information of worker):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How physically fit is your child? ______________________________________________
Do you think your child has any emotional difficulties?
Yes
No
If yes, please explain: ______________________________________________________
________________________________________________________________________
________________________________________________________________________
August 2002
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Relationships
How would you describe your relationship with your child?
________________________________________________________________________
________________________________________________________________________
If other children are in the home, how does your child relate to them?
________________________________________________________________________
________________________________________________________________________
Does your child tend to have
many or
just a few friends?
Are they mostly
boys,
girls, or both?
Comments: ______________________________________________________________
________________________________________________________________________
As far as you know, how does your child get along well with peers at school?
________________________________________________________________________
________________________________________________________________________
Does your child tend to play alone or with others?
________________________________________________________________________
________________________________________________________________________
Please describe your child’s personality (moods, temper, maturity level)
________________________________________________________________________
________________________________________________________________________
Please check the qualities that you feel best describe your child:
Friendly
Outgoing
Shy
Withdrawn
Carefree
Busy
Overactive
Lonely
How do you discipline your child?
_______________________________________________________________________
School
School:
Address:
Phone:
Grade:
August 2002
__________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Teacher:
_________________ ____________
Page 4 of 11
Does your child seem interested in school?
Yes
No
Has your child ever been involved in a special education program?
Yes
No
If yes, please comment: ____________________________________________________
Has your child ever failed a grade?
Yes
No
If yes, which one(s)? _______________________________
How does your child generally get along with the teacher? __________________________
How is your child doing in school? ___________________________________________
Do you think your child is doing as well as he/she can in school?
Yes
No
If no, please explain: ___
Does your child get in trouble at school?
If yes, is it
often?
Occasionally?
Yes
Seldom?
No
Social Activities
Is your child interested or active in sports, church, group activities?
Yes
No
If yes, please list:
________________________________________________________________________
________________________________________________________________________
Please indicate what hobbies, if any, your child currently enjoys.
________________________________________________________________________
________________________________________________________________________
Briefly describe your child’s weekly schedule of activities.
________________________________________________________________________
________________________________________________________________________
About a Big Brother/Big Sister
Is your child aware of your application for a Big Brother/Big Sister?
Yes
No
If yes, what was the reaction?
________________________________________________________________________
________________________________________________________________________
How do you feel your child would benefit most from a Big Brother or Big Sister?
________________________________________________________________________
________________________________________________________________________
Describe the type of Big Brother/Big Sister you would like for your child
________________________________________________________________________
________________________________________________________________________
August 2002
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What types of activities do you think your child would like to do with a Big Brother/Big
Sister?
________________________________________________________________________
________________________________________________________________________
Is there any information you would like to add to this application that will help us to serve
your child’s needs better?
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Confidentiality
Just as we have to share information with you about the Big Brother/Big Sister we select for
your child, we need to share information with the volunteer about you and your child. Is
there anything here that you do not want shared with a volunteer?
Yes
No
If yes, please clearly state what you do not want shared: ____________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________
Your Name
______________________________
Your Signature
____________________________________
Date
The answers you have given will help us to do our best for your child. Please be sure to
advise us of any changes in your home situation, such as address changes, relationship
changes, etc.
August 2002
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Big Brothers Big Sisters Association of Wood Buffalo
AGREEMENT: PARENT
1. Orientation:
I understand and am in agreement with the objectives of Big Brothers Big Sisters
Association of Wood Buffalo, through the orientation I have attended. I have received
information on the following:
__ philosophy and program of the Agency
__ criteria for volunteer acceptability
__ an overview of the screening and matching policy
__ an explanation of the Agency’s expectations of volunteers, parents and
children
__ an explanation of the Agency’s responsibility to children, parents and
volunteers
__ an explanation of the training for the prevention of child abuse (Child Safety
Program).
2. Child Safety Program:
I am aware that Big Brothers Big Sisters Association of Wood Buffalo is of the opinion
that sexual abuse prevention education is an effective preventative safeguard.
I am aware that it is the policy of Big Brothers and Sisters of Canada* to require all
Littles and their parents to attend a Child Safety Program, organized by the local Big
Brothers/Big Sisters organization. I also understand that all my children are welcome to
attend.
I agree that my child and I will attend the Child Safety Program, when scheduled.
Signature:
Witness:
Date:
August 2002
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CHILD INTEREST FINDER SHEET
The following 3 pages (7-9) are for the Little Brother/Sister to fill out
FIRST NAME: ______________________
AGE: _______
**PLACE AN X BESIDE YOUR ANSWER: CIRCLE YOUR 5 FAVORITES AFTERWARDS
Activity
Like
Dislike
Want to
Learn
Activity
1. Animals
26. Hunting
2. Archery
27. Ice Skating
3. Art
28. Jogging
4. Baking
29. Martial Arts
5. Baseball
30. Mechanics
6. Basketball
31. Models
7. Bicycling
32. Movies
8. Board Games
33. Music
9. Boating
34. Photography
10. Bowling
35. Pool
11. Camping
36. Quadding
12. Cards
37. Reading
13. Carpentry
38. Rollerblading
14. Collecting
39. Science
15. Computers
40. Snowmobiling
16. Cooking
41. Soccer
17. Crafts
42. Swimming
18. Dancing
43. Table Tennis
19. Downhill Skiing
44. Tennis
20. Fishing
45. Video Games
21. Football
46. Volleyball
22. Gardening
47. Walks in Park
23. Golf
48. Water Skiing
24. Hiking
49. Woodworking
25. Hockey
50. X-Country Skiing
Like
Dislike
Want to
Learn
Other: _________________________________
August 2002
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THE “ME” SHEET
COMPLETE THESE SENTENCES AS QUICKLY AS YOU CAN
PLEASE DO NOT SKIP ANY OF THEM
1. My School: __________________________________________________________
2. I am proud of: ________________________________________________________
3. I like________________________________________________________________
4. My dreams ___________________________________________________________
5. My mother ___________________________________________________________
6. My brother(s)_________________________________________________________
7. My sister(s) __________________________________________________________
8. I am sorry ___________________________________________________________
9. My father ____________________________________________________________
10. It makes me angry _____________________________________________________
11. My good friend is _____________________________________________________
12. Other kid’s my age ____________________________________________________
13. Boys ________________________________________________________________
14. Girls ________________________________________________________________
15. I worry most _________________________________________________________
16. My mother treats me ___________________________________________________
17. My father treats me ____________________________________________________
18. I am happiest when ____________________________________________________
19. I hope _______________________________________________________________
20. Policemen(women) ____________________________________________________
21. Sometimes people _____________________________________________________
22. Black _______________________________________________________________
23. White _______________________________________________________________
24. Adults ______________________________________________________________
25. Mud ________________________________________________________________
THANK YOU!
☺
We look forward to meeting you 
MORE “ME”
August 2002
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1. Do you want a Big Brother/Sister? _________________________________________
2. What kind of person would you want as a Big Brother/Sister: ____________________
_______________________________________________________________________
3. Your Big Brother/Sister will want you to think of things to do together. Would you be
willing to do this? ______________________________________________________
4. What outside activities do you like the most? _________________________________
_______________________________________________________________________
5. Do you belong to any group or team (e.g. sports, scouting) If yes, please list below. __
____________________________________________________________________
____________________________________________________________________
6. What quiet activities do you like most? _____________________________________
____________________________________________________________________
7. What things have you never done before that you would like to try with your Big
Brother/Sister? ________________________________________________________
____________________________________________________________________
8. Are there any activities that you do not like to do? If yes, what are they? ___________
____________________________________________________________________
9. When you are not in school, what do you spend most of your time doing? __________
____________________________________________________________________
10. Choose 5 words to describe yourself _______________________________________
____________________________________________________________________
11. What do you like about yourself? __________________________________________
____________________________________________________________________
12. What do you not like about yourself? _______________________________________
____________________________________________________________________
13. Which do you do most?
Play Alone ________
With A Friend _______
With A Group Of Friends _______
THANK YOU!
☺
We look forward to meeting you 
August 2002
Page 10 of 11
MEDIA CONSENT FORM – CHILD PERMISSION
I, _________________________________, hereby consent to Big Brothers Big Sisters Association of
Wood Buffalo to use any photographs, audio and/or video recordings of
_____________________________ as taken or produced by media personnel and/or Association Staff for
the purpose of publicizing and promoting the work of the Association. This includes radio, television,
newspapers, newsletters, and the internet. This means I authorize my pictures to be uploaded onto the
internet and the Big Brothers Big Sisters Website and waive all claims I have against the agency for any
issue arising from said publication. I further waive any claim which I may have against Big Brothers Big
Sisters Association of Wood Buffalo arising from the use of such photographs, audio and/or video
recordings of myself in any other way, as afore said.
This consent and waiver shall remain in effect for the duration of my involvement with Big Brothers Big
Sisters Association of Wood Buffalo unless otherwise revoked.
_____________________
Date
_____________________
Date
_____________________
Date
_______________________________________
Signature of Parent/Guardian
_______________________________________
Signature of Child (if over 12 years of age)
_______________________________________
Signature of Witness
************************************************************************
NOTE: Confidentiality concern
If you do not want your picture to be used, please check here:
Name: _________________________________
Date: _________________________________
Note: It is your responsibility to notify the office if the status of this consent changes
August 2002
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