Before You Start

Thank you for your interest in mentoring programs provided by Boys & Girls Clubs Big Brothers Big Sisters of Edmonton. On the following pages we will be asking you to provide personal information for the applicant and their parent or legal guardian. If you are referring a young person to one of our programs, we will also ask you for your basic contact information.

If you encounter any issues with this form please contact Melissa St. Dennis. You may also download a hard copy of the form here.
 
 
   
 
   
Young Person's Information 
Young Person's First Name* Middle Name Young Person's Last Name*
 
 
 
Preferred Name Date of Birth (MM/DD/YYYY)* Gender*
 
 
 
 
   
 
   
Address*
 
City* Province Postal Code*
 
 
 
Any plans to move?* If yes, when and where
 
 
 
 
   
 
   
Were you born in Canada* Ethnic Identity CIC Number (if applicable)
 
 
 
Additional languages spoken Will interpreter be required for any meetings? If yes, please tell us what type
 
Yes
No
 
 
 
   
 
   
Current school* Grade* Siblings (name and age)
 
 
 
Alberta Children's Services involvement If yes, what type of Involvement Worker Name & Phone EDM
Yes
No
 
Family Enhancement
Protection
 
 
 
   
 
   
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 

Parent/Guardian Information 
Parent/Legal Guardian Name* Relationship Type* Custody
 
 
 
Parent/Legal Guardian Primary Phone* Cell Phone  
 
 
Primary Caregiver Business Phone Ext  
 
 
Parent/Legal Guardian Email*
 
Best time for us to contact you
 
Other Ways to Contact
 
 
   
 
   
Other Parent/Guardian Name Other Caregiver Relationship Does the child live with this person
 
 
 
Other Caregiver Address
 
Other Caregiver City Other Caregiver Province Other Caregiver Postal Code
 
 
 
Other Caregiver Home Phone Other Caregiver Cell Phone Other Caregiver Work Phone
 
 
 
 
   
 
   
Emergency Contact Relationship* Emergency Contact Name* Emergency Contact Phone*
 
 
 
 
   
 
   
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 

Program Selection

From the drop down menu below, please select a program. 
Program Of Interest
 
What do you hope to gain by having mentorship in your child's life?*
 
Please list any other agencies you or your child is involved with?*
 
Please list any medical conditions or diagnosis*
 
   
   
 
   
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 


Referring Information

If you are referring a young person to one of our programs please enter your contact information.

If you are a parent or legal guardian, do not complete this section. Please click the "Next" button to continue.
 
Referring Person's name* Referring Person's E-mail*  
 
 
 
   
 
   
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 




Your Application Is Almost Complete

 
I agree that the information I have provided is true to the best of my knowledge.*
 
   
   
I authorize Boys & Girls Clubs Big Brothers Big Sisters of Edmonton and Area to use the information I provided within their agency.*
 
 
   
Please enter today's date (MM/DD/YYYY)*