Overnight Exception Application - Big Brothers Big Sisters Kansas City

Who is submitting this form?

Select one:(Required)

Big

Parent/Guardian

Big's Information

Primary Big's Full Name(Required)

First Name Last Name

Big's Date of Birth(Required)

Secondary Big's Full Name (If Applicable)

Secondary Big's Date of Birth (If Applicable)

Address(Required)

Street Address 1 Street Address 2 City State / Province / Region ZIP / Postal Code Country

Big's Phone(Required)

Big's Alternate Phone

Big's Email(Required)

Little's First and Last Name(Required)

First Name Last Name

How long have you been matched?(Required)

Match Support Specialist's Name(Required)

Little's Information

Little's Full Name(Required)

First Name Last Name

Little's Date of Birth(Required)

Little's Phone(Required)

Little's Email

Little's Allergies or Medical Considerations

Little's Blood Type (If Known)

Parent/Guardian Information

Parent/Guardian Name(Required)

First Name Last Name

Address(Required)

Street Address 1 Street Address 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Phone(Required)

Parent/Guardian Alternate Phone

Parent/Guardian Email(Required)

Emergency Contact Information

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Emergency Contact Alternate Phone

Emergency Contact Email(Required)

Overnight Activity Information

Date Proposed Overnight Begins(Required)

Date Proposed Overnight Ends(Required)

Please describe the plan for the overnight and the nature of the activities.(Required)

Please list who will be present at any time during the overnight. (Will there be anyone present besides the Big & Little? If yes, what is their relation to the Little or Big?)(Required)

Transportation (If the proposed plan includes travel outside city limits, what are the transportation arrangements?)(Required)

If an overnight visit is approved by the agency, the following conditions are required:(Required)

Yes