Lone Star Youth Application

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Welcome!

Dear Parent/Guardian,

Thank you for your interest in Big Brothers Big Sisters. 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, educational success and avoidance of risky behaviors. 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 either in person or using technology. Depending on your child’s needs and interests, these visits will consist of activities such as helping with homework, talking, or going to an event together. A Big Brothers Big Sisters staff member (called a Match Support Specialist) will monitor the progress of each relationship 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 Community Based or e-Mentoring program must meet the following criteria. They should:

· Be capable of benefiting from a relationship with a Big

· Want a Big and understand the role of a Big

· 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

We want to make sure that we find the best Big for your son or daughter. Just as it takes time for anyone to make new friends, it may take us a while to find the right Big. Bigs and Littles are matched based on parental preference, similar personality, background, geographic location, and shared interests.

If you have any questions, please contact us.

Thank you.

Child Intake Department

BBBS Lone Star

intake@bbbstx.org

Hidden Fields

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Program Choice

Which Programs are you open to (select all that apply) ?

Community Based Mentoring: at least 2 outings a month. Minimum 1 year.e-Mentoring: communicate at least 2-4 times a month through video technology (such as zoom, google hangouts), BBBS platform and other technology as allowed. Minimum 1 year.

Do you have a computer or tablet your child can use to communicate with their mentor?

Yes

Do you have reliable internet/ WiFi?

YesNo

Youth Information

Youth's First Name

Middle Name

Youth's Last Name

Youth's Preferred First Name

Youth's Birthdate

MM/DD/YYYY

Youth's Social Security Number

Enter a SSN in the following format: xxx-xx-xxxx

Youth's Gender	Write In - Gender
School Begin typing school name	Grade Level

Youth's School ID Number

School ID

Race/Ethnicity

Press CTRL while choosing to select multiple

Does the youth have their own phone?

YesNo

Youth's Phone

Does the youth have their own email?

Yes

Youth's Email

How would you describe the youth, in terms of participation in events, activities, or sports?

Which activities does the youth enjoy more?

What activities does your child enjoy doing?

Does the youth have any allergies?

YesNo

Allergies Description

Is the youth taking any medications?

YesNo

Medications Description

Does your child have any physical health challenges or diagnoses?

YesNo

Physical health challenges or diagnoses Description

Does your child have any behavioral, emotional or mental health challenges or diagnoses?

YesNo

Behavioral, emotional or mental challenges or diagnoses Description

Has your child received in-patient care at a mental health facility within the last year?

YesNo

If yes, please briefly describe (how long was hospital stay, when was release, what was the reason for admittance?):

Has your child been diagnosed with autism or autistic like behaviors?

YesNo

If yes, please provide a brief description of diagnosis:

Has the youth ever been involved with the police or juvenile justice system?

Yes

If yes, please provide approximate dates and a brief description of the involvement:

Guardian's Relationship to Youth

Youth Living Situation

Living Situation Description

Is there a person who shares custody of this youth?

YesNo

Custody is shared with:

Joint Custodial Contact Information (phone and email). Verbal consent from other custodial adult MUST be received in order to enroll your child

Does the youth have a parent/guardian who is currently incarcerated?

YesNo

Relationship to Child?

Does the youth have any family member who is currently incarcerated, on probation or parole?

YesNo

Relationship to Child/ Status (probation/parole/ incarcerated): List all that apply?

Example: Aunt/probation, Cousin/parole

Does the youth have any family member who is previously incarcerated, on probation or parole during your child's lifetime?

YesNo

Relationship to Child/ Status (probation/parole/ incarcerated): List all that apply?

Example: Aunt/probation, Cousin/parole

We receive grant funding for certain geographic areas in Tarrant County. Because of this, please indicate if your child spends a significant amount of time in any of the following zip codes (such as with other family members or in after school care). Please check any that apply.

76112761197610676164

If so, with who?

Example: Grandparents, Daycare , Rec Center, Family friends, etc.

Does the youth have a parent/guardian who is serving or served in the military?

Is the youth's parent/guardian currently deployed?

YesNo

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?

Race/ Ethnicity of the Mentor

YesNo

Preferred race/ ethnicity of mentor

Religion/ Faith of the Mentor

YesNo

Preferred religion/ faith of mentor

Marital status of the Mentor

YesNo

Preferred marital status of mentor

Age of the Mentor

YesNo

Preferred age of mentor

Sexual Orientation of the Mentor

YesNo

Preferred sexual orientation of mentor

Any other preferences about the Mentor

YesNo

Please elaborate on other preferences

Are you open to your child being matched with a sworn law enforcement officer (peace officer)?

YesNoTexas Law (Penal Code 46.15 authorizes sworn peace officers to bring firearms onto the premises of the school

If you are enrolling a son and your son is 11 or younger, we continually have more female volunteers than male volunteers and will be able to match your son sooner if you are open to a Big Sister. Are you open to a Big Sister, Big Couple, or Big Family?

YesNo

Is your child interested in having a mentor/Big?

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Household size

Mobile Phone

Other Phone

Preferred Phone

Best Time to Call

Personal Email

Work Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

Additional Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Family Information

Which community are you enrolling your youth in?

Location (County Selection)

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

State

Zip Code

Annual Household Income

Is the youth eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

Do you anticipate any significant life changes over the next year, or have you had any in the past year?

YesNo

Life Changes Description

How did you hear about Big Brothers Big Sisters?

Existing Household Members

Please choose this child's relationship to the following people:

Name:	Relationship:
App record ID	contact record ID

Child Pre-Interview Questionnaire

How many times have you moved in the last 2 years?

How long do you plan to live in your current community?

Has there been any Child Protective Service (CPS) involvement in the last 18 months?

YesNo

If yes, please provide approximate dates, and list the reason(s) and outcome

Has your child ever been physically aggressive towards children or other adults?

YesNo

If yes, please provide approximate dates, and list the reason(s) and outcome

Has your child ever acted out sexually around children or other adults?

YesNo

If yes, please provide approximate dates, and provide a brief description of the outcome

Has your child ever had suicidal thoughts or exhibited self-harming behavior?

YesNo

If yes, please provide approximate dates, and please describe

Is your child currently involved in any gang activity?

YesNo

If yes, please provide approximate dates, and please describe

In the past 18 months, has your child participated in any other risky behaviors not mentioned above? (For example: fire setting, stealing, compulsive lying, etc)

YesNo

If yes, please provide approximate dates, and please describe

Have you ever been contacted by an attendance officer of the school or the district or received any communication that your child's absences were a source of concern or potential difficulty?

YesNo

If yes, please provide approximate dates, and please describe

Family Support Services (FSS) Participant Enrollment Form - Youth & Family Programs

Program

Please select the appropriate program below

Fatherhood EFFECT (FE)Community Youth Development (CYD)Service Members, Veterans, and Families Program (SMVF)Family and Youth Success Program (FAYS)Statewide Youth Services Network (SYSN)Long-Term Youth and Family Support (LTYFS)

Authorization for Service

Contract ID No.

Subcontractor

Contract Workflow

Enrollment ID No.

Enrollment Start Date

Service Start Date

Planned Service Frequency

Staff Assigned to Family

Name of Person Completing Intake

Data Entry Staff Name and Data Entry Date

I have been provided information on the referenced Family Support Services Program and wish to receive services. I understand that data on my child/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 child/youth/family to participate in the program.

I AgreeI Disagree

Date

Name of Parent or Guardian

Index Child/ Youth Name

Index Child/ Youth Information

First Name

Middle Name

Last Name

Suffix

IIIIIIVJRSR

Date of Birth

SSN

Primary Phone

Primary Email

Hispanic Origin

HispanicNon-HispanicUnable to Determine

Race (select all that apply)

Index Child/ Youth - Primary Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Index Child/ Youth - Other Information

Disability Status

YesNoUnknown

Homeless Status

YesNo

Education Level

Current Living Situation

Previous Juvenile Probation/ TJJD Involvement?

YesNo

Expectant Parent

YesNo

Delivery Due Date

Education Status

Is your current living situation a temporary arrangement due to housing loss or economic hardship?

YesNoNot Assessed

If yes, when was youth last involved in Juvenile Probation?

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

KEEPING OUR LITTLES SAFE

What follows are tips that can help keep your Match safe and long lasting.

Parents/Guardians

· After every Match activity, ask your child some detailed questions about how the outing went.

· Make sure you are always informed of your child’s plans with his/her Big.

· Please be at home when your child is supposed to return from an outing.

· Be aware of your child’s phone conversations, online chats, or emails from his/her Big.

· Keep in regular contact with your Match Support Specialist. Share your thoughts and feelings.

· School Based Parents/Guardians should regularly ask their child about his/her Match and report to the BBBS Match Support Specialist any observations or concerns.

Littles

· Always tell your Parent/Guardian (whether they ask or not) what you and your Big do together.

· Be honest with your Parent/Guardian and about your feelings toward your Big. If you are unhappy or uncomfortable with your Match, tell your Parent/Guardian immediately.

· Stay with your Big when you go out on outings. Don’t go off on your own.

· Wear your seatbelt at all times.

· If you are in a School Based Match, stay on the school campus. Special permission from school administrators and staff supervision is required for off campus meetings and activities.

BEING A PART OF BIG BROTHERS BIG SISTERS

Families as Partners

We partner with Parents/Guardians, volunteers and others in the community to empower children and youth to achieve:

· Higher aspirations

· Greater confidence

· Better relationships

· Educational success

· Avoiding risky behaviors

Each year, we ask the Parent/Guardian to provide:

· Current report card at the end of each school year

· Standardized test (STAAR) results

MATCH AGREEMENT

Introduction

Big Brothers Big Sisters Lone Star aims to provide children with strong and enduring, professionally supported 1-to-1 relationships that change their lives for the better, forever. Our vision is that all children achieve success in life. Your involvement can help achieve the mission and vision of the agency by developing a healthy, successful, and impactful relationship between all parties. The Match Agreement sets forth what an appropriate and healthy match relationship is like. The Code of Conduct defines specific behaviors for match members to follow to develop and maintain an impactful match. BBBS takes a strong stance against behaviors that result in inappropriate or unhealthy relationships. The Match Support Team, led by the assigned Match Support Specialist, will guide Bigs, Littles, and Parents as they pursue this potentially life changing relationship. For the purposes of this document, the term “Parent” refers to biological parents, caretakers, legal guardians, and/or school personnel for site/school-based matches.

Match Agreements

Match Members (Big, Little, Parent, Match Support Team) agree to communicate regularly, openly, and appropriately about all aspects of the match friendship.

Match Members agree to interact consistently and faithfully for the life of the match and agree to end the match in a positive and appropriate way when the time comes.

Match Members agree to behave appropriately in all situations in order to keep the match relationship healthy, safe, and moving toward a positive impact on the child.

I.Communication is key to an appropriate and healthy match relationship.

A. The Match Support Team will be in contact with Bigs, Parents* and Littles each month to help the match develop a healthy, appropriate friendship, as well as keep the match engaged with the agency and its resources. To enhance their match relationship, the agency will also ask Bigs and Littles to complete surveys about their match relationship or trainings.

B. Regular communication between the Big and Parent is essential. Big, Parents and Littles will need to communicate with one another to schedule activities, discuss the Little’s development/progress, and to ensure the match meets everyone’s expectations. It is important to keep communication open and honest, especially when issues or disagreements arise.

C. Parents are in the best position to ensure that a healthy friendship develops. Parents and Littles will communicate after each meeting so the Parent can have a full understanding of what the match did together, how the child felt about the meeting, and what the child gained from the meeting.

D. To strengthen their friendship, Littles and Bigs will engage in conversation while meeting, over the phone, or via text (as appropriate).

E. Communication with the agency must always be open and honest, including if anyone ever has an uncertain or uncomfortable feeling about the match relationship.

F. In accordance with the law, all adults in Texas are required to alert the proper authorities if any situation arises where someone is in danger of being hurt, hurting others (including self), or if abuse or neglect of any child is suspected, disclosed or observed. If you ever find yourself in this situation, let the Match Support Team know so that they may guide you through the appropriate course of action.

G. BBBS is a mentoring agency and does not provide direct financial assistance or counseling services. If Parents, Littles, or Bigs are in need of financial, emotional or other assistance, the Match Support Team can make referrals to appropriate resources. Bigs and Littles/Parents assume no legal responsibility for each other resulting from the match relationship, are not responsible for providing direct assistance to each other, and are discouraged from doing so.

H. At some point in time, all matches end. BBBS hopes that each match lasts for a very long time. When a match needs to close, regardless of the reason, the Big, Little, Parent, and Match Support Team agree to communicate about the closure in order to provide the best possible ending for the match, with the well-being of the Little as the first priority.

II.Consistency and faithfulness from all parties of the match are essential for developing a healthy and appropriate match relationship. BBBS recommends the Big and Little meet face to face around 4 times a month (at least twice every month) and, generally speaking, no more than once a week.

A. Friendship and trust develop over time. Bigs and Littles will meet in person, one to one, and talk consistently throughout the life of the match relationship.

B. A friend is not a consequence to be taken away as a result of bad choices. Parents will support the match friendship between the Big and Little by allowing meetings to occur even if the Little has exhibited misbehavior in other areas of his/her life. Parents may restrict meetings to exclude activities that may feel like a reward to the Little, but will not restrict the Big and Little from seeing each other. Parents will encourage Littles to have positive behavior when interacting with Bigs during and between meetings.

C. There are times that things come up and plans must be changed. To be considerate, Bigs, Littles, and Parents will contact one another if something will prevent them from following through on confirmed plans.

D. Bigs, Littles, Parents, and the Match Support Team will faithfully protect each other’s personal information (upholding confidentiality) unless there is a concern for someone’s safety and then appropriate authorities will be contacted.

E. BBBS does not discriminate with regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, age, military or veteran status, disability, and/or any other legally protected class. Bigs, Littles, Parents, and Match Support Team members may find that they have differing values and views than those they are matched with, but are to respect the different values and views each brings to the match relationship. BBBS will not tolerate, and will take appropriate action if, harassment or discrimination of others is reported or discovered.

III.Appropriate behavior on the part of all parties is necessary to ensure the development of a healthy match relationship.

A. The Big and Little should be part of each other’s lives, but not to the exclusion of other activities and people.

B. A mentor models good decision-making skills. Match meetings will be safe and appropriate for the Little based on age, maturity level and interests. Parents will be consulted when deciding in which activities the match will participate. The Match Support team can provide consultation and assistance with ideas when needed.

C. Friendship is not built with money or gifts. In planning activities together, Bigs, Littles, and Parents will keep costs low so that the focus of time together will be on building a lasting friendship between the Big and Little.

1. The Big will be responsible for covering the cost of activities that the match agrees to participate in together; however, Parents are welcome to help with costs as they are able.

2. Since the focus of the match is to build a healthy and appropriate relationship between the Big and Little, the giving of money, special favors or excessive gift giving will be avoided. For guidance on gift giving, consult your Match Support Team member.

D. Bigs introduce Littles to new experiences. Community Based Littles may visit the Big’s home only after they have been matched for three months and the Match Support Team and Parent approves the visit. However, the match will continue to engage in a variety of activities in the community with occasional activities in the Big’s home. (See Home Visit Policy)

E. Overnight visits may only occur with prior approval from the Match Support Team and only when the requirements of the Overnight Policy have been met. (See Overnight Policy)

F. Appropriate supervision will be provided for the Little at all times. Both Parent and Big will take responsibility for their part in supervising the Little. The Big is responsible for appropriate supervision during meetings, and the Parent is responsible for making sure appropriate supervision is available during pick up and drop off times for meetings.

G. Bigs and Littles will respect each other’s personal space, boundaries, and privacy.

H. Parents will be the sole individual responsible for administering discipline and medical treatment for the Little.

I. Community Based Bigs will provide a safe experience while transporting their Little including following all traffic/auto laws and recommendations of the State of Texas.

J. Bigs will notify the agency of any changes in their life circumstances, legal status, or health that would result in the Big no longer meeting the eligibility requirements to be a Big or to provide safe transportation for their Little on outings.

K. Bigs will recognize that they are considered role models for their Littles and will exhibit behavior and make choices that reflect that role model status both in the presence of the Little and in other areas of their lives (including complying with all local, state, and federal laws). Criminal background checks may be conducted on the Big each year that they remain in the program.

DISREGARD OF MATCH AGREEMENT/CODE OF CONDUCT

The signature of the Big, Little, and Parent on the Receipt of Forms document indicates the understanding of and willingness to abide by the Match Agreement, Code of Conduct, and policies/regulations of Big Brothers Big Sisters Lone Star. Any exceptions to the Agreement/Code of Conduct must be requested and approved in advance by a Match Support Specialist or Supervisor. If Bigs, Littles, or Parents disregard the Match Agreement, Code of Conduct, and policies/regulations, immediate review and possible closure from the program could occur.

I have read the youth safety guidelines and ground rules which define my responsibilities as the parent/guardian of a Little. I agree to abide by them as long as my youth is in the program and I understand that BBBS has the right to close my youth’s match at any time.

Confidentiality Policy

Please read this document in its entirety.

As a potential participant of Big Brothers Big Sisters Lone Star (BBBSLS or BBBS), I understand that I have access to confidential information about volunteers and/or clients and families. I fully understand and accept the responsibilities inherent in my role to maintain the complete confidentiality of all personal information, documents and parties who are engaged in this partnership (collectively, the “Confidential Information”), including myself, BBBSLS and all its affiliates and employees, public figures as well as all children and families that are served by this partnership. The obligation of confidentiality persists indefinitely and is not limited to the period of time beginning with my participation in BBBS and ending at the close of my participation.

In order for BBBSLS to provide responsible and professional services, it is necessary for volunteers, clients and parent/guardians of clients to disclose personal information. BBBSLS respects the confidentiality of client/volunteer information. Confidentiality applies to written records, electronic records, voice, verbal statements, pictures (motion or still) and the use of client/volunteer’s name in agency publications. All records are considered property of the agency, not of agency staff, partner agencies, clients, parent/guardians or volunteers.

I further agree to the following terms:

In the event that an actual breach of confidentiality or a release of Confidential Information has occurred or if a situation which I reasonably believe may result in a breach of confidentiality comes to my attention, I agree to immediately notify the designated BBBSLS representative and/or any other appropriate BBBSLS staff member. I understand and agree that I am required to report such breach or threatened breach of confidentiality regardless of whether the breach is caused by my own actions or by the actions of another person.

According to the Confidentiality Policy, information from client/volunteer records may only be shared with individuals/organizations as specified:

· Identifying information regarding client/volunteer may be used in agency publications or promotional material only if the client/volunteer has given written permission.
· Information shall be provided to law enforcement or courts only with a valid, enforceable subpoena.
· Information shall be provided to BBBSLS legal counsel in the event of litigation or potential litigation involving the agency.
· State law requires that suspected or disclosed child abuse, exploitation or neglect be reported to the Texas Department of Protective and Regulatory Services, Child Protective Services.
·   Information regarding match relationship and match closure reasons shall be provided to other BBBS agencies and youth serving organizations if requested.
·   If agency staff receives information that indicates that a client/volunteer may be dangerous to himself/herself or to others, steps shall be taken to protect the appropriate party, including a report to the law enforcement authorities.
· When a child/volunteer is considered for a match, information is shared between the prospective parties. The identity of the parties is not revealed until after the parties agree to the match. Each party has the right to refuse the proposed match based on the anonymous information provided. Information shared may include: age, sex, race religion, education, interests, hobbies, marriage and family status, living situation, sexual orientation, reasons for applying to the program, expectations for match participation, a summary of the reasons an individual was chosen for the match, and all other information deemed relevant. The individuals to whom the information is provided shall agree not to share the information with any other person.
·    Certain outside bodies, including members of the Board of Directors, may have access to client/volunteer records for the purposes of program evaluation, audit, accreditation, and/or for purposes of operating and making available approved software, on-line sites and login portals. All such authorized persons and representatives shall enter into a Confidentiality Agreement before receipt of any information from client/volunteer records.
·  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.

Other than in the instances set forth above, information from client/volunteer records shall not be released unless accompanied by an authorized consent to release information form signed by the client/volunteer. If the client is under the age of 18, the consent to release information form must be signed by the student’s parent or guardian.

Thank you for your careful consideration and willingness to uphold the privacy and confidentiality of those participating in Big Brothers Big Sisters.

I have read and understand the above information provided to me regarding Big Brothers Big Sisters' confidentiality policy. I agree to the conditions set forth.

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 a questionnaire 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 my child to communicate with their volunteer and BBBS in person, over the phone, using text, using BBBS/iMentor platform, using other virtual technology, using mail and/or via email; (7) for my child to be transported by their volunteer/staff member for outings (8) to Big Brothers Big Sisters for release of information regarding my child participating in the following**: Photographs, TV & Movies and General Information.

**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.

I understand and consent to that all records are 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. I consent to communication via texting, phone, email and mail or other technology platforms. Our BBBS platform 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.

Date

I Agree

By selecting the "I Accept" button you are signing this agreement electronically. You agree that your electronic signature is the legal equivalent of your manual signature.

I Accept

Parent Printed Signature

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