A man and a boy wait for dark to use their telescope

Little Sign Up & Information Request Form

                                              


Child's Information

Child's First Name:  

*

Child's Last Name:   *
Parent/Guardian's First Name:   *

Parent/Guardian's Last Name:  

*
Child's Date of Birth:   *
Address:   *
Unit:  
City:   *
State:   *
Zip:   *
 Parent/Guardian Phone:

Parent/Guardian Email:

Your Contact Information (person filling out this form, if not P/G)

First Name:   *
Last Name:   *

Primary Phone:  

*

Secondary Phone:  

Email:  

*
   

What is your relationship to the child?

Relative:  

Parent/Guardian

Step-Parent

Grandparent

Aunt/Uncle

Other Relative:

 

Non-Relative:  

Foster Parent

Case Manager / Social Worker

Teacher

Counselor

Clergy

Other Non-Relative:

   
A Little needs to be able to make a minimum one-year commitment once matched or one school year for site-based Littles. Are you and the child willing and able to meet this commitment?
   
 

 

 

 

 

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