Youth Application BSW

Application

Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. Children are not excluded on the basis of race, religion, national origin, color, gender, sexual orientation, disability, gender identity, veteran status, or marital status of parent.

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

Gender	Student ID:
School Start typing name of school	If your school is not listed, please choose "other" and enter here.
Grade2026/27 school year:	Graduation Year This is the year the youth will graduate.
School Account ID:

Race/Ethnicity

Press CTRL while choosing to select multiple

Does the youth have their own phone?

YesNo

Youth's Phone

Living Situation Description

Is there a person who shares custody of this youth?

YesNo

Custody is shared with:

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

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

Existing Household Members

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

Name:	Relationship:
App record ID	contact record ID

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Parent/Guardian Agreement

By signing below, I give permission:

1. For my child to participate in the Big Brothers Big Sisters Beyond School Walls Program

2. For my child to be transported by a school district bus to the site location and back to their school;

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

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 receive communication from Big Brothers Big Sisters of Central Carolinas staff via phone call, email and/or text (SMS) messages.

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, waive, and hold harmless 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 sponsored 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. I also understand that my child’s relationship is considered site-based and will only occur at this time during the school year unless approved by Big Brothers Big Sisters beforehand.

I accept the terms and conditions.

YesNoI understand that by choosing no, my child may not be able to participate in the BBBS program.

Parental/Guardian Publicity Consent Form

I, as the legal parent or guardian of the child named below (“Minor Child”), irrevocably consent for myself and Minor Child to any and all uses and displays of my or Minor Child’s name, image, likeness, appearance, and basic biographical information in, on, or in connection with any advertising, publicity, marketing, or printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America, Big Brothers Big Sisters of Central Carolinas, and any of their affiliates, successors, partners, sponsors, donors, and any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type without further consent from me or Minor Child, without any royalty, payment, or other compensation to me or Minor Child, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use.

Opt InOpt Out

Minor Child's Name:

Summer Contact

To further enhance your child's site-based match relationship, would you be interested in your child's big contacting them during the summer months via text messaging, phone calls, emails, or postcards?

YesNo

Signature Block

I have read the above statements and accept them as conditions for participating in the Big Brothers Big Sisters of Central Carolinas program. All parties agree that electronic/digital signatures are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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

Printed Signature:

Poor Grades	Skipping school/Classes
Truant	Behavior problems
Suspended	Expelled
Sent to an alternative school	No