Enroll Your Child

Guardian Information

Guardian First Name

Guardian Last Name

Guardian Email

Guardian Mobile Phone

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP at any time to opt-out of further messaging. We will never sell, share or trade your name or personal information with any other entity

Guardian Street Address

City

State

Zip Code

Spanish preferred?

YesNo

How did you hear about the program?

Child's Information

Child's First Name

Child's Last Name

Your Relationship to Child

Child's Date of Birth

Child's Gender

FemaleMaleNon-BinaryPrefer to self-describe

Please share your child's race and select all that apply. Hold the control key down to select more than one option

BBBSEM is committed to being an anti-racist organization. We use racial indicator information to hold our agency accountable as we strive for greater equity.

How long has the child lived in the current home?

Do you expect the child to be moving in the next 12-18 months?

YesNo

Does the child have any physical, mental or behavioral challenges?

YesNo

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP at anytime to opt-out of further messaging. We will never sell, share or trade your name or personal information with any other entity.

We’re here for you.