Little Sister Referral Form
Note: Required items have an Asterisk *
Child's Full Legal Name:*
Date of Birth:*
Parent's / Guardian's Preferred Phone Number (one required): Home Cell Work :
Regular Special Ed
Interests / Hobbies:
Number of Siblings:
Sibling's Sex & Ages:
Full Legal Name:*
Highest grade completed:*
Elementary High School Technical School College
Out of home?
Contact with Child?
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