Young Person Application 

Thank you, for your interest in programing provided by Boys & Girls Clubs Big Brothers Big Sisters of Edmonton and Area. 


On the following pages, we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information. Our agency will keep information provided confidential, based on our agency policy. 

Our agency works hard to create a safe, respectful, and inclusive environment for all who are involved with our programs. Sensitive information collected will only be used in a professional manner. Information we collect on gender identity, pronouns, preferred and legal names are used to find the right mentor for you and to create a safe space. If it is not safe for the agency to use the information provided, such as pronouns, please let us know how to best support you. 

If you encounter any issues with this form, please contact: Jenna Brewer at jenna.brewer@bgcbigs.ca or 780-822-2518.

Boys & Girls Clubs Big Brothers Big Sisters of Edmonton and Area embodies the principles of diversity and welcomes the participation of all regardless of race, religion, culture, or sexual orientation. Our agency works to create a safe, respectful and inclusive environment for all who are involved with our programs.
 
 
 
 
 
 
 
 
Young Person's Information  
Please Choose the Program that Best Fits the Young Person's Needs 
 

Circle Support Services: Support for young people between the ages of 6 and 24 years old. This program is for young people who are referred from a partnering agency.

Diversion First: Support for young people between the ages of 12 and 17 years old. This program is for young people who are referred to the by the Edmonton Police Service.

 
Young Person's Program of Interest *
 
 
 
Young Person's First Name*
 
 
Young Person's Last Name*
 
 
Young Person's Preferred Name (If different from first name)
 
 
Date of Birth (DD/MM/YYYY)*
 
 
Gender*
 
 
Specified Gender Identity If Not Listed
 
 
Pronouns *
 
 
Pronouns Specified If Not List
 
 
 
Young Persons Email
 
 
 
 
 
 
 
 
 
 
Address*
 
 
Apartment Number
 
 
City*
 
 
Province*
 
 
Postal Code*
 
 
 
 
 
 
 
 
 
 
 
Was the Young Person born in Canada?*
 
 
Cultural Identity*
 
 
Immigration Number/ Permanent Resident Card Number (if applicable)
 
 
Newcomer Status
 
 
Additional languages spoken
 
 
Preferred Language of Communication*
 
 
Will an interpreter be required for any meetings with young person or family?
 
Yes
No
 
If yes, please tell us what type of interpreter and what language
 
 
*If an interpereter is required BGCBigs will provide one free of cost.  
 
 
 
 
 
 
 
 
School that the young person will attend during the 2024/2025 school year*
 
 
Grade young person will be in during the 2024/2025 school year*
 
 
 
 
 
 
 
 
 
Does the family currently have involvement with Children's Services?*
 
 
If yes, what type of involvement?
 
 
Social Worker name and contact information
 
 
 
 
 
 
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
Parent/Guardian Information

On the following pages we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information.Our agency will keep information provided confidential, based on our agency policy. 
  
Please provide information for the applicant (young person's) Primary Caregiver(s), Parent(s), or Leagal Guardian(s). We have provided space for 2 individuals, but only one primary caregiver is required. The primary caregiver will be the main contact person.  
 
Full name of Parent/Legal Guardian *
 
 
Does the Young Person live with this person?*
 
 
Relationship type*
 
 
Caregiver Specified Relationship Type if not previously listed
 
 
 
Custody of Young Person*
 
 
Who does the Young Person live with? *
 
 
 
Parent/Legal Guardian primary phone number*
 
 
Alternative phone number
 
 
Parent/Legal Guardian Email*
 
 
Best time of day to contact this person
 
 
 
 
 
 
 
Full name of other Parent/Guardian
 
 
Other Parent/Guardian relationship type
 
 
Does the Young Person live with this person
 
 
Other Parent/Guardian Address (If different from Primary Caregiver)
 
 
Other Parent/Guardian City
 
 
Other Parent/Guardian Province
 
 
Other Parent/Guardian postal code
 
 
Other Parent/Guardian primary phone number
 
 
Other Parent/Guardian alternative phone number
 
 
Other Parent/Guardian work or business phone number
 
 
 
 
 
 
Information provided will remain confidential. All programs are free and open to all young people, family income is not used to determine in program acceptance. If you would perfer not to disclose income on this application at this time you are able to do so.  
Income Source*
 
 
An estimate of your annual household income *
 
 
Number of people in household*
 
 
 
 
 
 
 
 
 
Siblings (Name, Age, Gender)
 
 
 
 
 
 
 
 
 
Emergency Contact Name*
 
 
Emergency Contact Relationship*
 
 
Emergency Contact Phone*
 
 
 
 
 
 
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
Program Information 

On the following pages we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information.Our agency will keep information provided confidential, based on our agency policy. 

  
Tell us about the young person, and their need for services*
 
 
 
 
 
Please list any medical conditions or diagnosis of the young person*
 
 
Alberta Health Care Number*
 
 
 
 
 
 
 
Please list any allergies or dietary requirements (vegetarian, Halal, Celiac, does not eat pork, etc.)
 
 
   
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
Thank You for Completing the Application 

On the following pages we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information.Our agency will keep information provided confidential, based on our agency policy.  
 
As the Parent/Legal Guardian, or the Referring Individual I authorize Boys and Girls Club Big Brothers Big Sisters of Edmonton and Area to use the information provided within their agency. I am consenting to receiving programs and services for my family, or contact to be made with this family.*
 
 
 
 
 
I agree that the information I have provided is true to the best of my knowledge. I acknowledge that some information will need to be shared with funding bodies as part of our agreement with municipal, provincial and federal funding sources.*
 
 
   
 
 
I consent that this document acts as my electronic signature and permission. *
 
 
 
 
 
Full name of Parent/Guardian completing form*
 
 
Email of Parent/Guardian completing form *
 
 
Name of Referring Individual
 
 
Name of Referring Organization/Agency
 
 
Email of Referring
 
 
 
 
 
Please enter today's date (MM/DD/YYYY)*
 
 
 
Client