Big Sisters of Greater Racine, Inc. Referral of Child for Big Sisters Program
Date *
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Child's Name *
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Address *
Street/City/Zip
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Parent/Guardian Phone (cell, home and/or work) *
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Child's Date of Birth *
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Grade *
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Race *
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Child's School *
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Is the child in a regular classroom? *
Is the child in special education? *
Children's interests/hobbies *
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Does the child have any physical limitations or allergies? *
If yes, please list all limitations and allergies.
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Child lives with?
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Mother's Name *
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Mother's Date of Birth *
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Grade Completed *
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If out of home, any contact with child? *
Mother's Employer *
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Hours/Shift Worked *
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Father's Name *
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Father's Date of Birth *
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DD
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If out of home, any contact with child? *
Father's employer *
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Hours/Shift Worked? *
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Number of Siblings and Ages *
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