BBBS Shoals Community Based Youth Application

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All information contained in this application will be kept in strictest confidence. Please read the information carefully, answer all the questions, and indicate your permission in the appropriate spaces.

Thank you for your interest in the Big Brothers Big Sisters program. All information we receive from you, your child, and other sources will be used to assess your child’s needs and eligibility for the program.

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

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?
School	Teacher's Name
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

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

Which activities does the youth enjoy more?

What are the child's favorite hobbies and activities?

Describe your child's personality and behavior

Explain any special needs of your child

Why are you signing this child up to receive a Big Brothers or Big Sister?

Does the youth have any allergies?

YesNo

Allergies Description

Is the youth taking any medications?

YesNo

Medications Description

Pertinent Medical History

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

What was their 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:

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

YesNo

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

Is the youth's parent/guardian currently deployed?

YesNo

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

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

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

Physical Address

Street Address

City

State

Zip Code

Annual Household Income

Number of persons in the home

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

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Parent/Guardian Agreement

APPLICATION FOR SERVICE

I hereby make formal application to Big Brothers Big Sisters of the Shoals, Inc. to make available the services of a Big Brother or Big Sister to my child and if possible, assign him or her an adult volunteer. I hereby release Big Brothers Big Sisters of the Shoals, Inc. of all responsibilities and liabilities in connection therein (as a result of the misbehavior or negligence of any adult volunteer assigned as a Big Brother or Big Sister to my child). I understand that the final decision as to whether my child is assigned to any given volunteer is mine. I understand that if I have a grievance, I may at any time contact the CEO at the agency address. In the event it is not resolved, I may present my grievance personally to the Board of Directors of the organization. I further authorize Big Brothers Big Sisters to release such information as it deems necessary concerning myself and my child to any prospective Big Brother or Big Sister volunteer.

I hereby give permission to my child's school to furnish Big Brothers Big Sisters of the Shoals, Inc., any information requested for their evaluation of my child.

I accept the terms and conditions

Medical Release

If an emergency, sickness or accident takes place, every attempt will be made to contact the parent/guardian. If a BBBS staff person or volunteer deems it necessary to seek medical attention for the applicant child while in their care:

I agree to authorize medical care. I do NOT agree to authorize medical care.

Confidentiality Policy

1. All client and volunteer information is confidential. This includes the information gathered from the parent, child, volunteer, and from any other contacts.

2. All client and volunteer information and documents are to be stored in the office in a locked filing cabinet and are not to leave the office without the permission of the CEO. Offices are to be locked whenever an employee leaves the building.

3. All information gathered by the agency concerning volunteers, clients, or parents is the property of the agency and is not available for their review.

4. All staff, volunteers, and board members are to sign a pledge of confidentiality form to be kept on file at the agency.

5. Only the members of the executive committee and program committee of the board of directors are authorized to review files and must obtain specific consent from the board authorizing each review and stating the purpose of such review. Those members reviewing case records are to adhere to confidentiality policies.

6. For case file reviewing related to program auditing purposes, the Program Committee may not review the files of other board members, immediate family of board members, close friends or business associates, staff members, or immediate family of staff members. Files for review will be selected by CEO and Program Manager.

7. For purpose of program evaluation, BBBSA may be authorized by the board of directors to review the files.

8. Information from case records may be released to other agencies only upon the receipt of authorization for such release signed by the parent (and/or client, if the client has reached the age of 18) or volunteer.

9. Information from case records may be released only to the court upon receipt of a valid subpoena. A valid search warrant allows immediate access to agency files. The agency should attempt to satisfy the subpoena or warrant with copies of the file instead of the original files. Information shall be provided to the agencies legal counsel in the event of receiving a subpoena, a search warrant, or threat of litigation. Such information is considered privileged and its confidentiality is protected by law. An interpretation of information in the case record can be given over the phone.

10. When discussing a potential match with a volunteer, the volunteer should be given the full name of the parent and child before being told any other information. Only after it is determined that the volunteer does not have any pre-knowledge/relationships/conflicts with the family will additional information be disclosed to the volunteer.

11. When confidential information is needed from sources such as therapists, counseling centers, or other agencies which the volunteer, client, or parent has served in or been served by, the staff shall obtain an authorization request and release of the information signed by the parent or volunteer.

12. State law mandates that suspected child abuse be reported to the appropriate authorities. All staff are responsible for staying abreast of such reporting requirements and shall comply with mandated procedures. The release of necessary information to report suspected child abuse is not a breech of confidentiality.

13. If a staff or board member received information indicating that a client, volunteer, or parent may be of danger to themselves or others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or a report to the local law enforcement authorities. The CEO and program committee chairperson must be informed before, or if this is not possible, as soon as possible after a report is made and a report of this report will be kept in the agency files.

14. Staff member or board members found to have violated confidentiality policies will be subject to removal at the discretion of the executive committee. Both board and staff members may be liable for legal action should breech of confidentiality occur.

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.

Social Media Consent

PUBLICITY RELEASE

In order that we may recruit Big Brothers and Big Sisters, we often do publicity with the children enrolled in our program. This publicity may include, but not necessarily: television, slide shows, photographs, website, Facebook, public appearances, etc. It is not necessary that you sign the statement below. It will not effect your child’s eligibility for service.

I hereby give my permission for my child’s first name and picture to appear in any advertisement or publicity for Big Brothers Big Sisters of the Shoals, Inc.I DO NOT give my permission for my child’s first name and picture to appear in any advertisement or publicity for Big Brothers Big Sisters of the Shoals, Inc.

I give permission for my youth’s Big to post pictures or videos of them online.I do NOT give permission for my youth’s Big to post pictures or videos of them online.

Telephone Consumer Protection Act Consent

I authorize that Big Brothers Big Sisters of the Shoals, Inc. has my consent to contact me regarding any matter related to the Big Brothers Big Sisters program, agency activities and events, and any other informational notices deemed important by the agency at the current or any future number that I provide for my landline, cellular phone or other wireless device using automated telephone dialing equipment or artificial or pre-recorded voice or text messages. I understand that I do not have to agree to receive autodialed calls or automated text messages to apply or enroll but that if I don’t, I may fail to receive valuable information. I understand that it is my responsibility to notify the agency if there is a change or disruption in any of the phone numbers provided.

I agree to be contacted by BBBS staff via text message about agency activities, events, parties, and free tickets for Littles.I don't want to be contacted by BBBS staff about agency activities, events, parties and free tickets for Littles.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

· The child is encouraged to call the Big Brother/Sister. Parent should monitor the time and length of calls.

· The parent, child and volunteer should stay in contact with the Match Support Specialist, notify the Match Support Specialist of any problems that may arise and ask for help from the Match Support Specialist as needed.

· The parent does not request the Big Brother/Big Sister for transportation, money, to babysit or to fix things around the house.

· No legal relationship (i.e. custody or guardianship) is established as a result of the relationship between the volunteer and child and should any problem arise, the Big Brother/Big Sister will not intercede for the parent.

· The Big Brother/Sister does not include any members or friends of the Little Brother/Sister’s family in activities nor does the parent request that he/she do so.

· No overnight visits are allowed except in exceptional cases and must be preapproved by the CEO.

· Little may not visit the volunteer's home until they have been matched for 3 months and both have completed a Strength of Relationship survey and a visit to the home has been approved by the Match Support Specialist. Visits to the volunteer's home should be limited to 2 per month.

· Respect the child’s privacy when it comes to bathing and changing clothes.

· If the child is too young to leave completely unattended, check on the child, but do not remain in the bathing area the entire time.

· Inform the parent of any picture taking or videotaping involving the child.

· Viewing of sexually explicit films, movies, photographs, or magazines is not allowed. Confer with the parent when making movie selections.

· Report any change in job, marital status, telephone number, or home address to your Match Support Specialist.

· Wear your seat-belts, bicycle helmets, or life vest. Safety is a priority!

· Respect confidentiality in this friendship as you would with your peers.

Have fun and enjoy being a part of the Big Brothers/Big Sisters program!

I have read the above 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.

Page 7

Assumption of Risk and Release of Liability Regarding COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend wearing masks and social distancing.

Big Brothers Big Sisters of the Shoals (BBBSS) provides the following guidance to participants in an effort to reduce the spread of COVID-19:

· -Restricted match activities to virtual platforms from April 5th, 2020 through June 4th, 2020.

· -After June 4th, 2020, allowed match activities while wearing masks and social distancing.

· -After June 4th, 2020, discouraged match activities that include additional individuals as well as crowded or populated venues.

· -Strongly discouraged any in person match contact if any party has been in contact with an individual known to have COVID-19 or who is experiencing symptoms such as a fever, dry cough, difficulty breathing, etc.

· - Strongly discouraged in person match contact if any party is a frontline worker who could have been exposed to COVID-19 through their profession.

Even with the above measures in place, BBBSS cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, permitting contact between match parties could increase your risk and your child(ren)’s risk of contracting COVID-19.

By submitting this application, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by permitting my child(ren) to participate in in-person match activities and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, BBBSS employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s participation in BBBSS program activities. The decision to re-engage in in-person meetings with my child(ren)’s mentor is my decision, not the decision of BBBSS.

On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless BBBSS, its employees, agents, board members, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of BBBSS, its employees, agents, and representatives, whether a COVID-19 or any other infectious disease occurs before, during, or after participation in any BBBSS program.

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