MENTOR APPLICATION/ ACES Program/ Y Achievers

(Adults Committed to Educating Students) Is student enrolled in Big Brothers Big Sisters? ☐Yes ☐No (If yes, only complete this section)

Student’s Name: Date of birth:

Gender: Male Female Race: ____ _____Current Grade: ______________

Name of School: Student email: _____________________________

Student Phone Number:___________________

Is English your family’s primary language? Yes No

If not, what language is spoken in your home?_________________________________________

Do you need translation services?____________________________________________________

Parent/Guardian #1 Name:

Age: ___ Race: Relationship to student: _____

Home Address: _________________________________

City: ___ State: Zip:

Marital Status: Single Married Separated Divorced Widowed

Place of Employment: Position:

Work Address: E-mail Address:

Cell Phone: ______ Home Phone: _____________________________

Parent/Guardian #2 Name: _____________________________________________________________________________

Age: ___ Race: Relationship to student: _____

Home Address(Check box if address is same as above ): ______________________

City: ___ State: Zip:

Who has legal custody of the child?___________________________________________________

Are there any siblings/family members currently involved with or applying for BBBS services? If yes, please

list:

_____________________________________________________________________

Is your student eligible for Free/Reduced Lunch: Yes No

Does your student have a family member who is or has been incarcerated in the past?

Yes No If Yes, who? _____

In case of emergency, whom should we call when we cannot reach you?

Name: Relationship to you:

Address: Phone:

Name: _______________________________________ Relationship to you:________________

Address: ______________________________________ Phone: _____________________ I am requesting Big Brothers Big Sisters service for my child and agree to cooperate fully with the program guidelines. I understand that I will be notified about whether my child has been accepted for service and placed on the waiting list only after we have completed the application/interview process. I also understand that if my child is placed on the waiting list, the agency cannot guarantee a match and that he/she will be assigned only when an appropriate volunteer is available.

Parent/Guardian’s Signature:______________________________ Date: ____________

Partnership/School Records Release Authorization

I understand and agree to the following as part of my student’s involvement in the Big Brothers Big Sisters’

ACES program:

My child’s grades, attendance, relevant disciplinary information and any other relevant information deemed

useful/necessary can be shared with my child’s mentor as well as BBBS staff by my child’s school

personnel. Please note: parent/guardian may be requested to advise the student’s school to release

previously stated information.

Parent/Guardian Name Parent/Guardian Signature Date

ACES Mentor Recommendation Form To be filled out by a non-family member who has known the applicant for one year and

is over 18 years of age.

Complete online at: www.bbbskc.org/acesrecommendationform Date: Student Name:

1. What school does the Applicant attend?

2. How long have you known the Applicant?

3. How do you know the Applicant?

4. What are the Applicant’s Strengths?

5. Has the Applicant discussed his/her plans for after high school with you? If so, what are they?

6. How will being matched with a mentor through BBBS benefit the Applicant?

7. Is there anything in particular you think BBBS or the Applicant's mentor should know about him/her?

Reference Information Name:____________________________________________________ Email: ______________________________ Phone Number:___________________________________