BBBS Lone Star      Site Based Parent Permission Form

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Dear Parent/Guardian,                                                                 

 

Your child has been invited to participate in the Big Brothers Big Sisters School Based/Site Based Program. To help you determine if the program is a good fit for your child, please learn more below.


What is the purpose?

The purpose of our program is for each enrolled child to achieve higher aspirations, greater confidence, better relationships, avoidance of risky behaviors and educational success. National research has shown that being in a positive relationship with a volunteer mentor (we refer to them as “Bigs”) has a direct and measurable benefit in a child’s life (we refer to the children in our program as “Littles”). Littles in our program:

·         Are more confident

·         Are more likely to stay away from drugs and alcohol

·         Do better in school

·         Get along better with family and friends

·         Feel better about themselves      

 

How does it work?

A Big will meet with your child on a one-to-one basis approximately 2-4 times a month at school or virtually utilizing technology.  Depending on your child’s needs and interests, these visits will consist of in person activities such as helping with homework, having lunch together, or going to the library OR virtual activities such as talking on the phone, interacting over web technology or taking virtual field trips. A Big Brothers Big Sisters staff member (called a Match Support Specialist) will monitor the progress of each match at the school and/or by phone to ensure the match is safe, everyone is happy with the match, and that the child’s needs are being met.

 

Who are our Bigs?

Our Bigs are volunteers in your community. They are students, retirees, members of organizations, and just ordinary adults. The safety of all children is extremely important to us, therefore each Big in our program must complete a thorough screening process conducted by our professionally trained staff. 

 

Who are our Littles?

Children in our School/ Site Based program must meet the following criteria. They should:

·         Be capable of benefiting from a relationship with a Big

·         Attend school regularly at a BBBS participating school/site

·         Want a Big and understand the role of a Big

·         Plan on attending the participating school for at least one full year

·         Have a parent/guardian willing to be a partner with us by maintaining contact and helping keep us informed of changes within the family/match    

 

By completing the attached permission form, you give consent for Big Brothers Big Sisters professional staff to conduct an interview with your child to learn their interests and goals. When your child is interviewed, they will bring home additional orientation and safety training information. We will then work to identify a Big who shares similar interests and can support your child to reach his/her fullest potential. Finally, your child will be matched with a Big and supported by a professional staff member.

 

If you have any questions, please contact your school representative.

 

Thank you.

Our Locations



Child's Information






Demographic Information                                                                                                                





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School Information





Parent/Guardian Information





Contact Information











Household




Mentor Characteristics
Do you have any preferences on the following characteristics of a Mentor who may be matched with your child as a Big Brother or Big Sister?













Texas Law (Penal Code 46.15 authorizes sworn peace officers to bring firearms onto the premises of the school
Grant Information
Big Brothers Big Sisters is supported by grants and other forms of funding that require the following information:












Example, Grandparents, Daycare, Rec Center, Family friends, etc.
Community Development Block Intake (CDBG)












I certify that all 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. 


Staff

Mark the approriate income category based on the number of individuals in the household:
1 2 3 4 5 6 7 8
VLI $17,150 $19,600 $19,600 $19,600 $19,600 $19,600 $19,600 $19,600
<50% LI $28,550 $32,600 $36,700 $40,750 $44,050 $47,300 $50,550 $53,800
<80% MI $45,650 $52,200 $58,700 $65,200 $70,450 $75,650 $80,850 $86,100
>;80% $45,651+ $52,201+ $58,701+ $65,201+ $70,451+ $75,651+ $80,851+ $86,101+


Prevention and Early Intervention (PEI) Division                             Client Registration Form

Program

Authorization for Service










I have been provided information on the referenced Prevention and Early Intervention Program and wish to receive services.  I understand that data on my youth/family will be collected, maintained, and entered into a secure database.  The information will be utilized to track services for evaluation purposes and to ensure quality services are being provided.  I hereby authorize my youth/family to participate in the program.



Target Client (Child/Youth) Information










Primary Address






Target Client (Child/Youth) - Other Information












Child Training Acknowledgement
You Have a Right to Feel Safe is a workbook for children ages 5-11 and Healthy Relationship for Teens is a workbook for youth ages 12-17. It goes over important rules that can help keep your child safe in Big Brothers Big Sisters programs and in life. Download and view BBBSA's You Have a Right to Feel Safe (5-11) or Healthy Relationships for Teens (12-17):

You Have a Right to Feel Safe (5-11)

Healthy Relationship for Teens (12-17)
Parent/Guardian Training Acknowledgement
Big Brothers Big Sisters' Number One Priority is the safety and well-being of your child. Please read the Youth Protection Education handout and take the training on BBBSA's The Learning Exchange
or
view the Parent Guardian Child Safety Training that we created especially for parents/guardians as they enroll their child in the program.
Parent Permission and Consent

I give permission (1) for my child to participate in the Big Brothers Big Sisters Program; (2) for the school, college, or university my child attends, or any other entity holding academic or other information about my child, to provide social, academic, and other information/ records about my child to Big Brothers Big Sisters Lone Star that are useful or necessary in assessing, planning or implementing educational interventions by BBBS staff (e.g. report cards, phone numbers, STAAR/ EOC exams/ standardized test scores, attendance records, behavior reports/ referrals, ARD meeting documentation, counselor and teacher reports, special education referrals and tests, free/reduced lunch status, etc.); (3) for BBBS to disclose information to school representatives for the purpose of assessing, planning or implementing educational interventions (e.g. identifying information such as name, school ID, and social security number); (4) to have my child complete questionnaires or surveys containing questions about school, the match relationship, personal interests, home life, etc.; (5) to have my child talk with a Big Brothers Big Sisters staff person about personal safety; (6) for my child to communicate with their volunteer and BBBS over the phone,  using BBBS/iMentor platform, using other virtual technology, using mail and/or via email; (7) if part of the program design that my child will be transported to another site for mentoring, to have my child transported by BBBS staff; and  (8) to Big Brothers Big Sisters for release of information regarding my child participating in the following**: Photographs, TV & video used for BBBS marketing purposes only.

**Big Brothers Big Sisters incorporates photographs, slides, films, television/radio tapings, and/or pictures for the sole purpose of promoting the agency in the media on local and/or national broadcasting affiliates.


 

I understand that no fees are charged for requesting a volunteer, and there is no guarantee my child will be accepted and/or matched. I recognize that the volunteer assumes no legal or financial liability for my child. I also understand that BBBS uses technology to enhance

personal match relationships.  I also understand that by signing this form I am giving

permission for my son/daughter (minor child named above) to participate in the program and activities of Big Brothers Big Sisters, and in connection with such participation, that he/she be assigned a volunteer Big Brother or Big Sister. In consideration of my child being permitted to participate in the program and activities of the agency, 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 parent/guardian. I understand and consent to that in order for Big Brothers Big Sisters Lone Star (BBBSLS) to provide responsible and professional services, it is necessary for clients and parent/guardians of clients to disclose personal information and I consent for the disclosure of such personal information related to my child as required for the participation of my child in the BBBSLS program.  

 

I understand that and consent for all records to be considered property of the agency, not of agency staff, clients, parent/guardians, volunteers or other authorized persons or representatives; information from the application, interview process, or match support process may be shared between BBBS, schools, and partnership agencies when applicable. I understand that personally identifiable information of students which is obtained from education records provided by any school district or school will only be used or re-disclosed by BBBS or its authorized representatives in accordance with requirements of the Family Educational Rights and Privacy Act (FERPA). Such information may not be re-disclosed to any third party (except back to the school district or school) without prior written consent of the school district or school, the parent or eligible student. Such information may not be used for any purpose other than the purpose stated in the agreement with the school district or school pursuant to which the information was obtained, and will only be disclosed to those authorized representatives of BBBSLS who have a legitimate interest in the program pursuant to which the information is provided. Our BBBS platforms allows

volunteers, youth, parents, and BBBS to connect securely using a web application. 

 

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 understand that Big Brothers Big Sisters does not exclude Clients, Parents/Guardians, Volunteers, Staff or Board Members on the basis of race, color, national origin, gender, gender identity, marital status, sexual orientation, veteran status, religion, or disability. All parties agree that electronic/digital signatures are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. A photocopy of this authorization may be accepted in lieu of the original.