1) * I am the child's legal parent or guardian- Yes No

2) * The child is at 7 years if a boy and 6 years of age if a girl?  Yes    No

If you have answered YES to all of the above questions, then begin to complete the form below.  If you have answered NO, please contact a Big Brothers Big Sisters and speak to a representative at (717) 397-7567 before completing this form. 

* Child's First Name    * Child's Last Name  

* Parent/Guardian First & Last Name

* Home Address 

* City   Zip     Cell Phone   

Day Phone     Evening Phone

   *  Please call me at-   Day     Evening     Cell

*  Email Address 

This email is my-    Home    Work 

* Child's Date of Birth   Race  Please Answer Other Caucasion African American Asian Hispanic Pacific Islander Native American Multi-Racial   * Sex  Please Answer Male Female

School Child attends        Current grade

* Parent/Guardian Employer  

Can you be contacted at work?  Yes     No

What is the primary reason that you believe your son/daughter would benefit from a Big Brother or Big Sisters? (please be brief)

*  How did you hear about the Big Brothers Big Sisters program?