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Bold Cousin Interest Form

Let's start with your personal details

What is your Date of Birth

What is your Gender

If you are filling this form out for someone else, please add their personal details in the box below, and continue the form from their perspective.

Where do you go to school?

What city are you in?

Are you pregnant?

Yes

How many kids do you have?

Do you need a car seat?

Yes

Why would you like to be connected with a Bold Cousin?

Help with social skills

Understanding money and budgeting

Navigating systems and services

Learning everyday life skills

Building confidence

Setting and reaching goals

I want guidance without judgment

I need a steady person in my life

Finding balance with school, work, and parenting

Feeling more independent

Getting encouragement and support

Spiritual Guidence

I would like my Bold Cousin to...

Go to doctor or school appointments

Help with baby stuff (shopping,classes, ect.)

Go to events ot support groups

Attend games or after school activities

Just hang out or talk

Do something fun sometimes

Help with errands or rides

I'm not sure

Other

What are you interested in

	Very Interested	Meh	Pass	Unknown
Music
Dance
Sports
Writing
Reading
Fashion
Hair & Makeup
Cooking/baking
Art/Drawing
Movies/Shows
Gaming
Animals
Gardening/Plants
Helping Others
Being outside/ Nature
Working out/ staying active
Parenting