COMMUNITY-BASED YOUTH APPLICATION AND PARENT/GUARDIAN PERMISSION FORM
Parent/Guardian Name:
Your answer
Relationship to child:
Your answer
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?
Name of Person You Share Custody With:
Your answer
Phone Number:
Your answer
Child’s First Name:
Your answer
Child’s Middle Name:
Your answer
Child’s Last Name:
Your answer
Preferred Name/Nickname:
Your answer
Child’s Gender:
Child's Date of Birth:
Your answer
What is the child’s living situation?
Parent/Guardian Phone Number:
Your answer
Parent/Guardian Phone Type:
Is it ok to text parent/guardian ?
Child Phone Number:
Your answer
Child Phone Type:
Is it ok to text child?
Home Address:
Your answer
City:
Your answer
County:
Your answer
State:
Your answer
Zip:
Your answer
Parent/Guardian E-mail:
Your answer
Child E-mail:
Your answer
Child’s School:
Your answer
Grade:
Your answer
Child’s Race/Ethnicity:
Required
Nationality/Country of Origin:
Your answer
Parent Place of Employment:
Your answer
Parent/Guardian Work Phone #:
Your answer
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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