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 Amy Jeske. 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
 
 
 
 
 
 
 
 
 
 
Was the Child born in Canada?*
 
 
Family's Cultural background?
 
 
Immigration Number/ Permanent Resident Card Number (if applicable)
 
 
Additional languages spoken
 
 
Will interpreter be required for any meetings?
 
Yes
No
 
If yes, please tell us what type
 
 
 
 
 
 
 
 
 
Current school*
 
 
Grade*
 
 
Siblings (name and age)
 
 
Do you currently have involvement with Child and Family Services?
 
Yes
No
 
If yes, what type of Involvement
 
Family Enhancement
Protection
 
Social Worker Name & Contact information
 
 
 
 
 
 
 
 
 
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*
 
 
If you were to estimate your household's annual income, what range would you select?*
 
 
   
 
 
 
 
 
 
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 and I am consenting to receive programs and services and that this document acts as my eletronic signature and permission*
 
 
 
 
 
Please enter today's date (MM/DD/YYYY)*