Referral Form

Child / Youth Information

Please read the following information and criteria carefully before completing a referral

To be a candidate for SPORTS BUDDIES:

Youth must be between the ages of 9 and 13
Priority is given to youth in a single parent home, kinship care, or non-traditional family
Priority is given to youth who are eligible for free or reduced lunch at school
Be available 1-2 Saturdays a month for events
The family must have transportation to take the child to and from the events. Unfortunately this program is not a good fit for families that use public transportation.

To be a candidate for COMMUNITY MENTORING:

Youth must be between the ages of 9 and 13
Priority is given to youth in a single parent home, kinship care, or non-traditional family
Priority is given to youth who are eligible for free or reduced lunch at school
Youth must be available to meet with their mentor at a minimum of two times a month

Please note:

Please discuss the program with the family / guardian first, confirm they are interested, and obtain permission before making a referral. If you have questions regarding enrolling a youth and have not spoken to the parent /guardian, please contact Tara Stiner at taras@biglittlecolorado.org
If the child does not meet our qualifications or is outside the 9-13 age range there are several other mentoring agencies operating in Colorado. Please Click Here for more information.

Child / Youth's FULL Name*

Date of Birth

MonthDayYear

Child's Age*

Gender*

Race / Culture*

Child's School

School District

Grade

Parent / Guardian Information

Parent / Guardian's Full Name*

Relationship to Child*

Phone Number*

Area CodePhone Number

E-mail

Home Address

City

Zip Code

Does the child qualify or receive free or reduced lunch at school?*

YesNoUnsure

What is the primary language spoken in the home?*

EnglishSpanishOther

The Sports Buddies Program requires transportation to the events, which would be 1-2 times a month on Saturdays. This program is typically not a good fit for families that rely on public transportation. If you are familiar with the family's transportation situation please indicate below:*

The family has a carThe family has access to a carThe family uses public transportationI am not familiar with the family's transportation situation

What is your primary reason for you wanting this child to have a Big Brother / Big Sister?*

Comments or Additional Information

If you are submitting this referral form, but you are not the child's parent/guardian, the following information is required. In keeping with Big Brothers Big Sisters of Colorado's confidentiality policy, if you have not spoken to the family about the program and received permission to make this referral we are unable to move forward until you have confirmed that permission has been granted. Thank you!

Referral Source Name

First NameLast Name

How do you know or work with this child?

E-mail

Phone Number*

Area CodePhone Number

If you are a professional that works with this child (teacher, social worker, counselor, other), what organization/school/agency do you represent?

Would you like us to follow up with you regarding this referral before reaching out to the family?*

Yes Please!No, you can follow up with the family directly

Before submitting this referral please confirm and check the following:*

I have spoken with the child's parent /guardian about this referral and confirmed they are interested in participating and learning more about the program.I have confirmed that the above phone number and email for the family is accurate and up to date.

Youth Referral Form