Referral Source and phone:
Is Parent/Guardian Aware of the Referral:	Yes  No
City of Saginaw Resident:	Yes  No
Date Referred:
Child's Name Referred:
Address:
City / Zip:
Birth Date:
Mother:
Mother's Address:
Mother's Phone:
Father:
Father's Address:
Father's Phone:
Parent's Place of Employment:
Email Address:
Work Phone:
School:
Grade:
School Year:
Siblings:
Birthdates:
Contact Person:
Contact Phone Number:

Church Child Attends:
Religion:
Church Address:
Pastor's Name:
Is one of the Child's parents currently incarcerated?	Yes  No
Has one of the child's parents been incarcerated within the past year?	Yes  No
Name of Incarcerated Parent:
Is / Was the parent in :	Jail  Prison

The following information is used for statistical purposes only. These statistics
are usually asked for when the Agency is applying for a grant. We are required
to provide the Community Development Block Grant with the source and amount
of monthly income for families who live within the city of Saginaw.

Why do you want a Big Brother / Big Sister for your child?