Little Sister Referral Form

Note: Required items have an Asterisk *

Child's Full Legal Name:*

Date of Birth:*

Race:

Home Address:

Street:*

City:*

Zip:*

Parent's / Guardian's Preferred Phone Number (one required): :

Home:

Cell:

Work:

Child's Information:

School Name:*

School Grade:*

School Type:

Lives with:

Interests / Hobbies:

Number of Siblings:

Sibling's Sex & Ages:

Physical Limitations:

Allergies:

Mother's Information:

Full Legal Name:*

Date of Birth:*

Highest grade completed:*

Out of home?

   

Contact with Child?

   

Employment Information

Employer Name:*

Work Hours:

Father's Information:

Full Legal Name:*

Date of Birth:*

Highest grade completed:*

Out of home?

   

Contact with Child?

   

Employment Information

Employer Name:*

Work Hours:

Reasons for Referral (Special Problems/Needs, Ways A Big Sister Could Help):*

Family Background (Current Family Situation):*

Description of Girl (Personality Characteristics, Behavior, Response to Adult Attention):*

Girl’s Reaction to the Referral:*

Suggestions as to Type of Big Sister (Particular Characteristics/Skills to Help):*

Referring Agency Information

The parent/guardian must be contacted by the referring agency to give permission for the referral of the child.

Parent / Guardian Contacted

Contact Date:*

Reaction:*

Agency:*

Referer Position:*

Referer Name:*

Phone:

E-mail: