COMMUNITY-BASED YOUTH APPLICATION AND PARENT/GUARDIAN PERMISSION FORM
Child’s First Name: *
Child’s Middle Name: *
Child’s Last Name: *
Preferred Name/Nickname: *
Child’s Gender: *
Child's Date of Birth: *
Parent/Guardian Name: *
Relationship to child: *
Do you have legal custody of the child? *
Is there a person who shares legal custody of this child? *
If yes, are they aware and supportive of the child’s enrollment in the BBBS program?
Clear selection
Name of Person You Share Custody With:
Phone Number:
What is the child’s living situation? *
Parent/Guardian Phone Number: *
Parent/Guardian Phone Type:
Clear selection
Is it ok to text parent/guardian ? *
Child Phone Number:
Child Phone Type:
Clear selection
Is it ok to text child? *
Home Address: *
City: *
County: *
State: *
Zip: *
Parent/Guardian E-mail: *
Child E-mail:
Child’s School: *
Grade: *
Child’s Race/Ethnicity: *
Required
Nationality/Country of Origin:
Primary Language Spoken in the Home *
Parent Place of Employment: *
Parent/Guardian Work Phone #: *
May we contact you (the parent/guardian) at the work number listed above? *
Please check the best number and time to contact you (the parent/guardian)? *
Required
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