BBBS: Refer a Child Client Inquiry Form

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Do you want refer a child to Big Brother Big Sisters of the Lehigh Valley? Refering a child can help improve a child's attitude toward school, academic performance, self-confidence, and help them avoid delinquency.

Before completing the form please read our client eligibilty requirements; once finished, complete all the fields and sections in the form and click "Submit." A member of our agency will contact you shortly thereafter to arrange a meeting and interview. In the meantime, feel free to continue to browse our site and discover more about our agency!

"Refer a Child" Form (Please read our eligibility requirments before proceeding.)
Child's Name:
Parent/Gaurdian's Name:
Child's Address:
City:
State/County:
Zip:
Parent/Guardian's Home Phone:
Parent/Gaurdian's Work Phone:
Child's Birthdate: (XX-XX-19XX)
Child's Age:
Child's Sex:


Are you the child's legal guardian?		YES		NO
Is an adult of the opposite sex living at home?		YES		NO

If yes, What is his/her relationship to the parent/guardian?


Does your child still see the absent parent?		YES		NO

If yes, How Often?


Have you inquired about this program before?		YES		NO

If yes, When? Month:	Year:


Do you have other children in the program?		YES		NO

If yes, List Names:


Why do you wish to make an application for service for your child?
(You may include any questions, comments, or suggestions you might have)

(Please press the submit button only "once")



Big Brothers Big Sisters of the Lehigh Valley, Inc. will provide services to any client regardless of race, creed, color, ancestry, national origin, sexual orientation, gender, or disability. Furthermore, Big Brothers Big Sisters of the Lehigh Valley, Inc. will accept qulified volunteers regardless of race, creed, color, ancestry, national origin, gender, sexual orientation, or disability. It is the responsibility of Big Brothers Big Sisters of the Lehigh Valley, Inc. to communicate bona fide qualifications regarding any prospective volunteer for consideration by the client, parent and/or guardian.