Young Person Application
Thank you for your interest in programing provided by Boys & Girls Clubs Big Brothers Big Sisters of Edmonton.
We encourage you to review our mentoring programs if you have not yet, to learn a little more about what we provide. Click
HERE
to learn more!
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. If it is not safe for the agency to use information provided, such as pronouns please let us know how to best support you.
If you encounter any issues with this form please contact Alexis Forbes at
alexis.forbes@bgcbigs.ca
or
780-490-6843
Young Person's Information
Please Choose the Program that Best Fits the Young Person's Needs
Big Brothers:
One on one, weekly mentoring for boys ages 6 to 18
Big Sisters:
One on one, weekly mentoring for girl ages 6 to 18
Club Programs:
Registered after shcool group programing for young people ages 6 to 18
NetWORK Mentoring
: Online one on one mentoring focused on empolyment readiness for young people ages 14 to 18
Virtual Mentoring
: Online one on one, weekly mentoring for young people ages 6 to 18
Virtual Reading
: Online reading support for young people in grades 1 to 3
Virtual Tutoring:
Online educational support for young people in grades 4 to 12
Virtual Group Programs:
Online registered after school group programing for young people ages 6 to 18
Program of Interest
*
Big Brothers
Big Sisters
Club Programs
NetWORK Mentoring
Virtual Group Programming
Virtual Mentoring
Virtual Reading
Virtual Tutoring
If you have chosen club programing as the selected program of interest you will be directed to choose the club location on the club registration form.
Young Person's First Name
*
Young Person's Last Name
*
Young Person's Preferred Name
Date of Birth (MM/DD/YYYY)
*
Gender
*
Male
Female
Transgender
Gender Non-Conforming
Specified Gender Identity
Specified Gender Identity
Pronouns
*
He, Him, His
She, Her, Hers
They, Them, Theirs
Ey, Em, Eir
Ve, Ver, Vis
Xe, Xem, Eyr
Ze/Zie, Hir, Hirs
Other
Pronouns Specified
Address
*
Apartment Number
City
*
Province
*
Postal Code
*
Was the Young Person born in Canada?
*
Yes
No
Cultural Identity
*
African
American
Asian-all other
Central American
English Canadian
European
First Nations
French Canadian
Indo China
Inuit
Metis
Middle East
Pacific Islands
South American
Southeast Asian
Undisclosed
Immigration Number/ Permanent Resident Card Number (if applicable)
Newcomer Status
Government Assisted Refugee
Convention Refugee
Family Class
Independent
Intent to Land
Student Visa
Refugee Claiment
Temporary Foreign Worker
Permanent Resident <3 yrs
Permanent Resident >3 yrs
Work Visa
Additional languages spoken
Preferred Language of Communication
*
English
French
Will interpreter be required for any meetings?
Yes
No
If yes, please tell us what type
Current School
*
Grade
*
Do you currently have involvement with Children's Services?
*
Yes
No
If yes, what type of Involvement
Family Enhancement
Protection
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.
Parent/Legal Guardian Name
*
Relationship Type
*
Mother
Father
Dual Guardians
Legal Guardian
Family Member
Worker
Other
Who does the Young Person live with?
*
Adoptive Parent(s)
Biological Parent(s)
Foster Home
Group Home
Kinship Care
Living Independently
Transient
Custody of Young Person
*
Sole
Joint
In Care - Permanent
In Care - Temporary
Does the Young Person Live With this Person?
*
Yes
No
Parent/Legal Guardian Primary Phone
*
Cell Phone
Primary Caregiver Business Phone
Ext
Parent/Legal Guardian Email
*
Best Time to Contact You
Morning
Afternoon
Evening
Other Ways to Contact
Other Parent/Guardian Name
Other Parent/Guardian Relationship type
Mother
Father
Step Mother
Step Father
Dual Guardians
Legal Guardian
Family Member
Worker
Other
The Young Person Lives With This Person
Other Parent/Guardian Address
Other Parent/Guardian City
Other Parent/Guardian Province
Other Parent/Guardian Postal Code
Other Parent/Guardian Home Phone
Other Parent/Guardian Cell Phone
Other Parent/Guardian Work Phone
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.
Income Source
*
Employed FT
Employed PT
Student
Employment Insurance
Social Assistance
Disability
Other
Undisclosed
An estimate of your annual household income
*
< 30,000
30,000 - 50,000
50,000 - 75,000
More than 75,000
Prefer Not To Disclose
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 other agencies, organizations, or activities the young person is involved with
*
Has the young person been involved with our agency previously?
Yes
No
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