Enroll a child today

It’s a big step for your little one. But we assure you it’s the right one. By enrolling your child with Big Brothers Big Sisters, you give them a chance to see their unlimited potential and develop into even more responsible, successful, well-rounded individuals. To get started, complete and submit the on-line application below or download an application now.

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Membership Application for
Little Brothers Little Sisters

Child's Sex: Male Female
Name: Birthdate:
Mailing Address: Street: City: Zip Code:
Child lives with: Home Phone:
Current School: Grade: Race: Religion:
Preferred Match Type: Community School

Family Information

MOTHER:

Name: Home Phone:
Mailing Address: Street: City: Zip Code:
E-Mail Address:
Employer & Occupation: Work Phone:
Race: Education: Birthdate:
Can you receive phone calls at work?: Yes No
 Best Time to Call:

FATHER:

Name: Home Phone:
Mailing Address: Street: City: Zip Code:
E-Mail Address:
Employer & Occupation: Work Phone:
Race: Education: Birthdate:
Can you receive phone calls at work? Yes No
 Best Time to Call:

GUARDIAN: (if child is not living with parent)

Guardian's name and relationship to child(i.e., grandparent, aunt/uncle, family friend, unrelated, etc):

HOUSEHOLD:

Please list anyone living in the home with your child, their ages and relationship to your child:

OTHER SERVICES:

Are you currently receiving services from any other agencies or institutions? Yes No
If yes, please list the services you’re currently receiving.
Does the absent parent pay child support? Yes No
Do you receive TANF benefits? Yes No
Does your child receive free or reduced lunch? Yes No
Other financial support? Yes No
If so, what?  

FAMILY HISTORY

If your child is being raised in a single-parent home, how did you become a single-parent?
Divorce         Death         Seperation         Desertion         Never Married
Please include date and cause of separation, divorce, or death:

Have there been any drug or alcohol abuse issues in the child’s family? Yes No
Has your child been sexually abused? Yes No
Has your child been physically abused? Yes No
If yes, by whom and when?
Was it reported? Yes No

DESCRIBE CHILD'S PERSONALITY

Please check those, which best describe your child:
Lack’s self-confidence
Wants his/her own way, bossy
School problems
Well-behaved
Responsible 		Assertive
Aggressive
Immature for age
Sensitive
Hyperactive 		Shy, withdrawn
Mature for age
Friendly, outgoing
Resents authority
Inactive, sedentary
Please add any other comments that would describe your child’s personality and behavior:

SUMMARY

How did you learn about our Program?

What are your expectations for your child through the Program?


Please list your nearest relative or friend, whom we can contact in case we can’t reach you or in case of an emergency:
  Phone:

Address:   Relationship to Child:

The information given in this application will be kept confidential and will be used by the Agency in matching your child with a Big Brother or Big Sister and to enable him/her to participate in activities.

PARENT/CHILD VOLUNTARY RELEASE

When a child and volunteer are considered for a match due consideration is given to those relevant factors that may significantly affect the volunteer/child relationship.

I hereby acknowledge, stipulate and agree that Big Brothers Big Sisters of the Black Hills is in no way obligated to assign, match or actively seek to assign or match a volunteer to my child. I further acknowledge, stipulate, and agree that Big Brothers Big Sisters of the Black Hills makes no guarantees, assurances, or other commitments, either express or implied, as to the impact or results of a match upon any of the parties involved. In recognition thereof, I hereby agree to hold harmless and free from any liability whatsoever the Big Brothers Big Sisters agencies, both local and national, and all agents and representatives thereof, resulting from any event, circumstance, or occurrence associated with their efforts.

I have read this document.
I understand it is a release of all claims.

TALENT/MEDIA RELEASE

I hereby consent to the use, sale, reproduction, transfer, or conveyance, of any and all photographs, images, likenesses, and voice recordings of my child in all forms (with or without the use of my name) by Big Brothers Big Sisters of the Black Hills, or by any designee of the Agency.

I hereby consent to the use of all forms of media including advertising, trade, display, editorial, art, exhibition and Agency newsletters (with or without my photograph and/or my name). I hereby give this consent and release to Big Brothers Big Sisters of the Black Hills, their nominees and designees from liability for any violation of any personal or proprietary right and agree to hold Big Brothers Big Sisters of the Black Hills harmless from all liability from the use, sale, reproduction, transfer or conveyance of the aforementioned items.

I give my consent
I DO NOT give my consent

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