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

Little Sign Up & Information Request Form


I/my child would like to become a Little Brother or Little Sister I would like more information about how to become a Little Brother or Little Sister
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?
YesNo

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Child's Information