White Square LogoAdult Site Based: Child Enrollment Form

Mentor Program


Child Information
Note: this information will be used ONLY to help choose the most beneficial match for your child.  This information will NOT be considered in determining whether or not your child is accepted into the program.




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This is the year the child will graduate high school.

Parent/Guardian Information



Please include unit or apartment #




Please include the slashes above.


By providing a mobile number, you give Big Brothers Big Sisters permission to contact you using automated text messages for reminders, updates, and events.










Emergency Contact
Additional Child Information





(ex. Peanuts, bees, penicillin)


(ex. EpiPen, Inhaler)



Note: Your child will be matched with a volunteer of the same gender.


Child Needs Assessment

Check all that apply


Check all that apply


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Confidential Information & Parent Permission
All information about your child is confidential and will not be released without your permission. Information about your child may be shared only with the teachers, counselors, school or youth partner staff, Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) staff and volunteer adult mentors involved in the matching process. Please be advised that this application becomes the property of Big Brothers Big Sisters of Orange County/Inland Empire.

Parent/Guardian Signature  
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Media Consent and Agreement

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

Initials
Initials


Parent/Guardian Signature  
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School Event Consent

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

Initials
Initials


Parent/Guardian Signature  
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Communication Consent & Agreement

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

Initials
Initials


Parent/Guardian Signature  
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RELEASE AND WAIVER OF LIABILITY

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: 



Parent/Guardian Signature  
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