Child Enrollment | Release of Information

By signing below, I give permission:

l . For my child to participate in the Big Brothers Big Sisters Program; until revoked by the Parent/Guardian with written

notice or a Successor Authorization, provided by Big Brothers Big Sisters of Indian River, St. Lucie and Okeechobee County is executed.

2. For the school/site to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports and academic screenings);

3. For BBBS to share demographic information, client records, and progress with certain outside bodies such as Big Brothers Big Sisters of America, Children's Services Council (CSC), Department of Education, etc. for purposes of

program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors;

4. To have my child participate in an enrollment interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests;

5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety;

6. For BBBS staff to provide contact information to the volunteer for the purpose of contacting my child.

7. To use my child's photograph and first name for the purpose of publicity efforts by Big Brothers Big Sisters:

I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I may be asked to provide additional information. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information shared in my child's in-take interview). I understand that my child may not meet with his/her mentor outside of school unless the match becomes an enhanced or community-based match, which requires further permission from the Parent/Guardian obtained via phone call by the case manager; I certify that all of the information on this form is true and correct and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my qualification for the program.

I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and

activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me as his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable. If my child is matched with a Big Brother or Big Sister I agree to support my child's match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff at least once per semester and once during summer break, and immediately reporting any concerns I might have to the school or Big Brothers Big Sisters staff.