Youth Application

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Thank you for your interest in Big Brothers Big Sisters!  

Below you will find information about our program and the youth application.  

Call us at 434.244.0882 with any questions.

 

Our Mission:  Create and support one-to-one mentoring relationship that ignite the power and promise of youth.


Who are our Littles?  Young people between the age of 6 and 16 that live in the City of Charlottesville, Albemarle, Fluvanna or Nelson Counties and could benefit from having a mentor. We ask that families make a one year commitment to the program.


Who are our Bigs?  Volunteer adult mentors from many walks of life.  Bigs can be college students, adults, or retired folks who understand that every young person in our community should have the chance to reach their full potential.  Volunteers are thoroughly screened before being matched with a youth.


Enrollment Steps:


Complete the application below. The confidential information you provide is submitted safely and securely here.


Attend Parent Orientation. Offered regularly one-on-one or in small groups, this orientation will tell you more about our program and explain what parents, youth, and volunteers can expect.  You will also get a chance to meet BBBS staff.


Parent/Youth  Interview. During the interview will will learn about you and your child.  This information your provide will insure we find the best match for your child.  


BBBS looks for the right volunteer. Once you’ve completed all the steps above, we’ll let you know if your child has been accepted into the program.  If so, once we’ve selected a Big that meets your child’s needs and interests, we will schedule a time for everyone to meet! Meetings take place at your home, at the BBBS office or another public place.  BBBS Bigs complete an application, provide references, are interviewed and have DMV, criminal and child welfare background checks.


Match Support. A BBBS Match Support Specialist will work with your family checking in every month for the first year to be sure your Little and their Big are on the right track.

Non-Discrimination Policy
Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability. 
Hidden Fields
To look up the owner's email for notifications
For notifications
Youth Information
Enter a date in the following format: mm/dd/yyyy
This is the year the youth will graduate.
Select all that apply
Select all that apply
Select all that apply
If none, enter N/A
Select all that apply
Guardian Information
Enter a date in the following format: mm/dd/yyyy
Press CTRL while choosing to select multiple
Type NA if unemployed
Please include first and last name
Family Information
Physical Address
Existing Household Members
Please choose this child's relationship to the following people:


Emergency Contact

Parent/Guardian Agreement

I give permission:

 For my child to participate in the Big Brothers Big Sisters Program (BBBS)


For the school to provide social and academic information about my child to  BBBS (e.g. report cards, behavior reports);


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


To have my child talk with a BBBS staff person about personal safety;


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

 

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 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 BBBS, communicating with BBBS staff at least once per month and immediately reporting any concerns I might have to BBBS staff.

Medical Release

As a Parent/Guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of my child/ward named above in the event of a medical emergency, which in the opinion of the attending physician may endanger his/her life, cause disfigurement, physical impairment, or undue comfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. Furthermore, I, the Parent/Guardian understand that I am responsible for any medical costs incurred, and will hold harmless Big Brothers Big Sisters of the Central Blue Ridge, Inc. and its Agents, Employees and Board of Directors, and I will fully reimburse any healthcare provider for medical care to my child/ward.

Confidentiality Policy

Access to Confidential Records

In order for BBBS of the Central Blue Ridge, Inc. to provide a responsible and professional service to clients, participants will be asked to divulge extensive personal information about themselves and their families. The agency 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. The right to confidentiality applies not only to written records, but also to video, film, pictures or use of client or volunteer's name in agency publications.

 

All records are considered the property of the agency and not the agency workers, clients or volunteers themselves. In order to provide a service which is in the best interest of the children served by the program, information from outside sources, including confidential references, must be assessed, along with information gained from the clients or volunteers themselves. Records are not available for review by the clients or volunteers and reasons for non-acceptance into the program will not be provided due to confidentiality issues. Clients and volunteers shall be provided a copy of this statement on confidentiality, along with the exceptions which define the limits of confidentiality, at the time of application.

 

Limits of Confidentiality

1.     Information will be released to other individuals or organizations only upon presentation of an authorized "consent to release information" form appropriately signed by the client or volunteer.

2.     Identifying information regarding clients and volunteers may be used in agency publications or promotional materials if the client or volunteer has given permission.

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. These outside organizations shall be required to respect the agency policy on confidentiality. Outside parties shall be required to use information only for the purpose(s) stated in the approval action of the Board of Directors.  

4.     Known violations of agency confidentiality policy will be reported to the supervisor of the individual involved and appropriate disciplinary action shall be requested.

5.     Members of the Board of Directors have access to client files only upon authorization by formal motion of the Board of Directors. The motion shall state who shall be authorized to review records, the specific purpose for such review and the period of time during which access shall be granted. Members shall be required to comply with the agency policies on confidentiality and may use the information only for purposes stated by the approved action of the Board of Directors. Known violations shall be reported to the Board President. A violation of the agency's confidentiality policy by a Board Member shall constitute adequate cause for removal from office.

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

7.     Information shall be provided to an agency's legal counsel, Board President, and the agency insurance carrier in the event of litigation or potential litigation involving the agency. Such information is considered privileged information, and its confidentiality is protected by law.

8.     State law mandates that suspected child abuse be reported to the appropriate authorities (VA Dept. of Social Services-Child Protective Services Unit). All workers are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.

9.     If any 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 medical referral or a report to the local law enforcement authorities. 

Media Consent

I, as the Parent/Guardian of the child named above, do give consent for Big Brothers Big Sisters of the Central Blue Ridge, Inc. to use photographs, images, and the voice of my child/ward, with or without names, in the various types of media in order to promote the agency. These types of media may include newspapers, brochures, radio ads and interviews, televisions ads, social media postings, agency reports, newsletters or displays.


In giving this consent, I release Big Brothers Big Sisters of the Central Blue Ridge, Inc. and its Agents, Employees and Board of Directors from any liability of any personal or proprietary rights I may have in connection with such use.

 

Youth Safety Guidelines and Grounds Rules for Parents/Guardians


·         I will make sure that my child has time to see their Big once per week, and I will be flexible with family plans if needed.

·         I understand that I will play an important role in supporting my child and their Big in their new friendship. I will treat the volunteer with respect.

·         I will not keep my child from seeing his/her Big as a form of punishment.

·         I will communicate directly with my child’s Big and approve match activities prior to their outing.

·         I will make sure that I am at home when my child is picked up and dropped off, or I will make other arrangements in advance.

·         I understand that the Big is not allowed to visit my child during regular school hours.

·         I will support my child’s Big in planning low-cost/no-cost activities.

·         I will be in contact with my Match Support Specialist (BBBS staff) every month for the first year of the match, and every three months thereafter.

·         I will respond to my Match Support Specialist in a timely manner. This means that I will check voice mail, return phone calls, answer texts, etc. within a reasonable timeframe.

·         If we need to close this match (i.e. moving out of service area), I will let Match Support know ASAP and help my child plan one last outing with their Big.

 

The following are very important rules. Breaking these rules can result in immediate match closure.

·         My child is not permitted to visit the Big’s home until a BBBS staff person completes an in-person safety assessment of the Bigs home.

·         My child will not participate in activities involving weapons such as firearms, handguns, zip guns, hunting knives, swords, explosives, etc. as these are strictly prohibited.

·         My child will not have overnight visits with their Big at any point during the match unless it is an agency-sponsored activity that both I and the Match Support Specialist have given permission for.


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