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Big Sisters of Greater Racine, Inc. Referral of Child for Big Sisters Program
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Nickname/Preferred Name
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Parent/Guardian Preferred Phone
*
Your answer
Parent/Guardian Cell Phone
Your answer
Parent/Guardian Work Phone
Your answer
Child's Preferred Phone
*
Your answer
Child's Preferred Email
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Required
Child's Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Child's School
*
Your answer
Child's Grade
*
Your answer
Is the child in a regular classroom?
*
Yes
No
Is the child in special education?
*
Yes
No
Children's interests/hobbies
*
Your answer
Does the child have any physical limitations or allergies?
*
Yes
No
If yes, please list all limitations and allergies.
Your answer
Child lives with?
*
Both Parents
Mother
Father
Other:
Mother's Name
*
Your answer
Mother's Date of Birth
*
MM
/
DD
/
YYYY
Grade Completed
*
Your answer
If out of home, any contact with child?
*
Yes
No
Mother's Employer
*
Your answer
Hours/Shift Worked
*
Your answer
Father's Name
*
Your answer
Father's Date of Birth
*
MM
/
DD
/
YYYY
If out of home, any contact with child?
Yes
No
Clear selection
Father's employer
*
Your answer
Hours/Shift Worked?
*
Your answer
Number of Siblings and Ages
*
Your answer
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