High School Bigs: Child Enrollment Form

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Mentor Program

Which mentoring program are you applying for?

Our "High School Bigs" program is one-to-one mentoring supervised and held on site at school

Program ID

Child Information

Child's First Name

Child's Middle Name

Child's Last Name

Mailing Street Address

Please include unit or apartment #

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Child's Date of Birth

Gender

Race/Ethnicity	How does the child identify?
School Start typing to search

School Account ID

School District

High School Graduation Year

This is the year the child will graduate high school.

Current Grade Level

Student ID

Is the child eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

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

YesNo

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

Is the child's parent/guardian currently deployed?

YesNo

Annual Household Income

Number of people supported by this income:

Household Living Situation

Living Situation Description

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

What was their involvement?

Parent/Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Mobile Phone

Can we send texts to the mobile phone number provided above?

Yes, I agree to receive updates, reminders, and event opportunities text messages from Big Brothers Big Sisters. Agreeing to this isn't a condition of participation in the program. I agree to the Terms of Service and Privacy Policy. Approx. 4 Msgs/Month. Msg & data rates may apply.

Home Phone

Work Phone

Work Phone Extension

Preferred Phone

Best Time to Call

Does the child have their own phone?

YesNo

Child's Phone

Parent/Guardian's Relationship to Child

Personal Email

Work Email

Preferred Email

Contact Preference

Parent/Guardian's Preferred Contact Language

Employer

Type NA (not applicable) if unemployed

Employer City

Type NA (not applicable) if unemployed

Is there a person who shares custody of this child?

YesNo

Custody is shared with:

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Child

Additional Child Information

What time does your child get out of school?

Is your child enrolled in the after-school program at this school?

YesNo

How will your child get home from the High School Bigs program?

Will be picked up by mother, father, or guardianHas permission to walk home alone Will return to a different after school program after the High School Bigs program

Pertinent Medical History

Please mark boxes to indicate if your child has any of the following health conditions:

AsthmaAllergiesDiabetesSeizuresOther

Allergies Description

(ex. Peanuts, bees, penicillin)

Is your child taking any medications?

YesNo

Medications Description

(ex. EpiPen, Inhaler)

Does your child have any mental health concerns (currently in therapy, emotional or behavioral plan at school, ADHD, etc.)?

Describe your child's environment and family structure?

Do you have any preferences regarding the volunteer who may be matched with your child as a Big Brother or Big Sister?

Note: All female children will be matched to a Big Sister

How did you hear about Big Brothers Big Sisters?

Referral Detail ID - IE

Child Needs Assessment

My child needs assistance in the following areas:

School PerformanceFriendship & Peer RelationshipsSelf-Esteem & ConfidenceOtherCheck all that apply

Please explain:

In what others areas have you noticed your child needs guidance?

Select multiple by holding down the CTRL key

Within the last year, has your child been in any trouble at school?

Running AwayClassroom BehaviorFighting or BullyingNot at this timeCheck all that apply

Please explain:

Permission Form

Program Description: One-on-one mentoring supervised and held on site at school. This fall (2020), all sessions will be virtual.

1. I, the parent/guardian of ___type name below___ , hereby give my permission for him/her to participate in the Big Brothers Big Sisters of Orange County/Inland Empire ("BBBSOC/IE") High School Bigs Program (the "Program") at my child's elementary school.

2. I understand that my child will be matched one-to-one with a volunteer Big Brothers Big Sisters high school mentor. The mentoring will take place weekly, on the campus of my child’s elementary school.

3. I hereby release my child’s elementary school of liability during my child’s participation in this program.

4. I understand that for my child to participate in this program, he/she will be interviewed and

photographed by BBBSOC/IE; this is for identification purposes only, subject to the Media Consent and Agreement below.

5. I understand that all information received will be kept confidential, within the agency’s limits of the law, except for purposes associated with the Program. California law requires that all professionals who work with families and children under the age of 18 report suspected and known incidents of child abuse, as well as threats of harm to self or others.

6. I, the undersigned, understand that all information my child or I disclose to BBBS, whether disclosed in the Child Enrollment Form, questionnaires, interviews or otherwise, and whether in writing or orally, may be disclosed to the prospective or matched Big Brother/Big Sister and I hereby consent to such disclosure.

7. I understand that all information obtained through the application process is the sole property of BBBSOC/IE .

8. I understand that my child and I will be contacted via telephone or mail by BBBSOC/IE

staff to discuss my child’s participation in the program.

8. I understand that BBBSOC/IE requires access to my child’s school records for the purpose of program evaluation. I hereby permit BBBSOC/IE to access my child’s grades, attendance and other school records as necessary.

10. I give permission for BBBSOC/IE staff to talk with my child about personal safety. I have reviewed the attached child safety information and program guidelines.

11. I give permission for my son/daughter to walk home alone from school after the High School Bigs program:

YesNo

12. I have read and understand the above statements and agree for my child to participate in the High School Bigs mentoring program.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Media Consent and Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”). I hereby accept the invitation of Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) for My Child to appear and be identified in print or online in any BBBSOC/IE publication or production. I hereby grant BBBBSOC/IE and its affiliates the absolute right and permission to use the image, name, and biographical information of My Child as BBBBSOC/IE may desire, in all media and in all forms whatsoever, including, but not limited to: magazines, brochures, press releases, print publications; motion pictures, television, cablecast and satellite broadcasts; the internet and mobile applications. Examples include, but are not limited to, the Orange County Register and other print news media, televised news media, promotional print media, and the BBBSOC/IE website and social media channels. In consideration of $0 to be paid to me, I hereby grant to BBBSOC/IE and its affiliates the absolute right to use images made through BBBSOC/IE studios or elsewhere, in whole or in part, in true or distorted character or form, alone or in conjunction with any other image, name or reproduction, in color or otherwise, for art, advertising, promotion, business, trade, or any other lawful purpose whatsoever, in perpetuum. I hereby waive any right that I may have to inspect and/or approve of the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied.

I hereby release BBBSOC/IE and its affiliates from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSOC/IE ’s exercise of the right hereby granted. These include, without limitation, claims for compensation, claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory. BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Initials

2. I do not grant Big Brothers Big Sisters of Orange County/Inland Empire the right to use the image of the minor child specified below.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relationship to Participant

Program Behavioral Policy

It is important that staff maintain order and discipline in all programs. Top objectives in all BBBSOC/IE programs are safety and a positive atmosphere for learning and developing skills. The staff makes every effort to help children understand clear definitions of acceptable and unacceptable behavior. A child’s behavior is expected to be consistent with the following: Use appropriate language at all times, cooperate with staff and follow directions, respect other children and staff, equipment, facilities and yourself, maintain a positive attitude, keep hands, feet and other objects to self and stay in program areas. Behaviors Resulting in Immediate Program Dismissal but are not limited to: ● Any action that could threaten or pose a direct threat to the physical/emotional safety of the child, other children or staff. ● Fighting or bullying ● Possession of a weapon of any kind ● Vandalism or destruction of school property, program property or property of others. ● Running Away ● Biting Parents/guardians are required to inform BBBSOC/IE in writing prior to a child’s acceptance in the program of any special circumstances which may affect the child’s ability to participate fully and within the guidelines of acceptable behavior, including, but not limited to any serious behavioral problems or special circumstances regarding psychological, medical or physical conditions.

Accidents/Illness/Emergency: When a child becomes ill or is injured during the program, the parent/guardian will be contacted immediately. If the parent cannot be reached our staff will adhere to the emergency contact information on your child's registration form. Please notify us immediately if changes occur in addresses, phone numbers or emergency contacts for your family. Should we not be able to reach anyone, we will call 911 for transport to needed medical facilities. I have read and understand the above statements and agree for my child to participate in the High School Bigs mentoring program.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Communication Consent & Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

Given the current school closures and ongoing uncertainty surrounding the COVID-19 pandemic, we understand that this can be a difficult time for your family to try and navigate. While the High School Bigs Program rules and guidelines typically do not allow Bigs or mentors and Littles or mentees to exchange contact information (such as phone numbers or email addresses), we are able to make specific exceptions and would live to provide our participants with options to stay connected.

1. I am the parent/guardian of the minor child specified below (“My Child”), who is participating in the High School Bigs Program (the “Program”) offered by Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) as a volunteer mentee, or “Little”. I hereby consent and give My Child permission to communicate virtually and/or electronically with My Child’s Big or mentor. Such communication may include, without limitation, telephone, text message, email, and video conferencing programs such as Zoom, CommandLink, Google Classroom, and FaceTime.

I WILL COMMUNICATE WITH MY CHILD, WITH MY CHILD’S BIG OR MENTOR, AND WITH BBBSOC/IE TO DETERMINE WHICH COMMUNICATION METHODS AND PLATFORMS I APPROVE.

I further agree to supervise, monitor, and otherwise stay informed about My Child’s virtual and/or electronic communication with My Child’s Big or mentor, and to maintain an open dialogue with My Child concerning these virtual and electronic interactions.

I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, volunteers, agents, affiliates, successors, and assigns, arising out of or attributable to My Child’s virtual and/or electronic communication with My Child’s Big or mentor, and other Littles or mentees participating in the Program.

BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Initials

2. I do not consent or give My Child permission to communicate virtually and/or electronically with My Child’s Big or mentor, or other Littles or mentees participating the program.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relationship to Participant

RELEASE AND WAIVER OF LIABILITY

I, the undersigned, am the parent and/or legal guardian of ___type name below___ , a minor (“My Child”), and I agree to permit him/her to attend and participate in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) High School Bigs Program (the “Program”).

I understand that certain risks and dangers may exist in My Child’s attendance and participation in the Program, and such attendance and participation is conditioned upon my agreement to release BBBSOC/IE from any claims of liability, including, but not limited to, any claims for property loss or personal injury to My Child. Therefore, in exchange for the opportunity of My Child to attend and participate in the Program, I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, agents, affiliates, successors, and assigns (collectively, “Releasees”), on account of injury, death, property damage, or economic loss arising out of or attributable to My Child’s participation in the Program, including, without limitation, to travel to or from their school/site or field trip/program destinations, whether arising out of the ordinary negligence of BBBSOC/IE or any Releasees or otherwise. I covenant not to make or bring any such claim against BBBSOC/IE or any other Releasee, and forever release and discharge BBBSOC/IE and all other Releasees from liability under such claims. This waiver and release does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that California law does not permit to be released by agreement.

I understand that by signing this agreement, I am waiving for My Child any and all claims, of any kind arising out of or attributable to My Child’s participation in the Program, including those claims that may be unknown to me, or which I do not suspect to exist at this time. WITH THE INTENTION OF WAIVING ALL UNKNOWN AND UNSUSPECTED CLAIMS, I HEREBY EXPRESSLY WAIVE ALL RIGHTS, BENEFITS, AND PROTECTIONS I MAY HAVE UNDER CALIFORNIA CIVIL CODE SECTION 1542, WHICH READS AS FOLLOWS:

“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.”

I shall defend, indemnify, and hold harmless BBBSOC/IE and all other Releasees against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys’ fees, fees and the costs of enforcing any right to indemnification under this agreement, and the cost of pursuing any insurance providers arising out of or resulting from any claim of a third party related to My Child’s participation in the Program, including any claims arising out of my own negligence, the negligence of My Child, or the ordinary negligence of BBBSOC/IE.

THIS AGREEMENT PROVIDES BBBSOC/IE WITH MY ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE BBBSOC/IE FOR ANY CLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relation to Minor Participant

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