BBBS East TN Child Application

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

Youth Information

First Name

Middle Name

Last Name

Preferred Name

Birthdate

Enter a date in the following format: mm/dd/yyyy

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?
Sexual Orientation	Please specify
School	Graduation Year This is the year the youth will graduate.

School ID

Race/Ethnicity (press CTRL to select multiple)

Does the youth have their own phone?

YesNo

Youth's Phone

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Birthdate

Enter a date in the following format: mm/dd/yyyy

Gender

How do you identify?

Personal Pronouns

What pronouns do you use?

Sexual Orientation

Please specify

Race/Ethnicity (press CTRL to select multiple)

Relationship Status

Guardian's Relationship to Youth

Mobile Phone

Home Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Work Email

Alternate Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Knoxville Office: Anderson, Blount, Knox, Sevier

Tri-Cities Office: Carter, Hawkins, Roane, Sullivan, Washington

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

Youth Living Situation

Living Situation Description

Existing Household Members

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

Name:	Relationship:
App record ID	contact record ID

Is there a person who shares custody of this youth?

YesNo

Custody is shared with:

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Parent/Guardian Agreement

I give permission for my child to participate in the Big Brothers Big Sisters program. I understand that the BBBS agency is not obligated to match my child with a volunteer and that as a part of the enrollment process I will be asked to provide additional personal information to the agency. If my child is matched with a Big I agree to support my child’s match and to immediately report any concerns I might have to the Big Brothers Big Sisters staff. I also understand that my child and I must complete scheduled, mandatory match support and surveys. I agree to continue to complete those throughout the length of my child's match.

I accept the terms and conditions

Virtual Platform Agreement

Big Brothers Big Sisters has developed a digital platform to help Bigs and Littles stay in touch more easily in a safe and secure way. Participation requires your permission.

I consent, should my child be matched, to having my child contact their Big through the BBBS digital platform. I DO NOT consent, should my child be matched, to having my child contact their Big through the BBBS digital platform.

Confidentiality Policy

Big Brothers Big Sisters of East Tennessee respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.

All records are considered the property of the agency and not the agency workers or clients or volunteers themselves. Records are not available for review by the clients or volunteers.

1. Information will be released to other individuals or non-BBBS organizations only with the client or volunteer's written consent.

2. Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteer request otherwise.

3. For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies such as Big Brothers Big Sisters of America may have access to client and volunteer records.

4. Members of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors.

5. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena.

6. Information shall be provided to an agency's legal counsel in the event litigation or potential litigation involving the agency.

7. State law mandates that suspected child abuse be reported to the Tennessee Department of Children's Services.

8. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities.

9. At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. The information about the volunteer may include such items as: age, sex, race, religion, interests, hobbies, marriage, family status, sexual orientation, living situation, etc. Information about the child may include such items as age, sex, race, religion, interests, hobbies, family situation, etc.

I agree to program participation under the above conditions. I further agree that I will not share identifying confidential information with anyone outside the agency, including family, friends, or community members, without the written consent of the persons involved (parent or guardian of a client or youth volunteer, or the adult volunteer). I also acknowledge that such information should be shared judiciously even within the ranks of Big Brothers Big Sisters, only with persons who have a specific need to know the information, and only in situations where others would not overhear such communication.

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.

Release of Information: Please check the following areas in which you agree to authorize the release of information:

MEDICAL RELEASE: I hereby authorize Big Brothers Big Sisters of East Tennessee to exchange the following information: diagnosis, evaluations, medications, progress notes, prognosis etc., to assist in evaluation and matching.SCHOOL RELEASE: I hereby authorize Big Brothers Big Sisters of East Tennessee to exchange general and scholastic information to assist in the evaluation and matching process.RELEASE OF INFORMATION TO POTENTIAL BIGS: I hereby authorize Big Brothers Big Sisters of East Tennessee and potential Big Brothers/Sisters to exchange information

DISCLAIMER: I understand that this consent automatically expires 90 days after the closing date of this case at Big Brothers/Big Sisters of East Tennessee, Inc. unless an earlier date is specified. I am aware that this consent is subject to written revocation by me at anytime.