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Child Information
*
Name of Child:
*
Date of Birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
*
School:
*
Grade:
Teacher:
*
Which Program are you interested in?
Community
Site/School
Parent/Guardian Information
*
Name:
*
Referred By:
*
Address:
*
City:
*
State:
*
Zip:
Email Address:
Home Phone:
Work Phone:
*
May we contact you at work?
Yes
No
*
What is the primary reason for wanting your child to have a Big Brother/Sister?
*
How do you think your child would benefit from having a Big Brother/Sister?
*
Are there any issues/conditions that might affect your child's ability to relate to a Big Brother/Sister?
