Parent/Youth Community Based Application

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 this format: mm/dd/yyyy
This is the year the youth will graduate.
Press CTRL while choosing to select multiple
NA if not applicable
We receive funding to support the following groups of youth. Please choose all that apply to your youth. 
Parent/Caregiver Information
Type NA if unemployed
When are the best days of the week for your youth to get together with their Big? Mark all that apply. (Please take into consideration all of your youth's activities outside of school.)
Family Information
Physical Address
Existing Household Members
Please choose this child's relationship to the following people:


Emergency Contact

CONSENT TO PARTICIPATE 

 

I give my consent for the youth who is named below, of whom I am the parent or legal guardian to participate in the Big Brothers Big Sisters Program.  I understand that the BBBS agency is not obligated to match my youth with a volunteer and that as part of the enrollment process I will be asked to provide additional personal information.  I understand that the minimum length of involvement is twelve (12) months and the involvement will be one to one activities in the community between my youth and the volunteer. My youth will be matched with a volunteer who has been screened and approved by Big Brothers Big Sisters. The volunteer may transport my youth to events, activities and to the volunteer’s home. If my youth is matched with a Big I agree to support my youth’s match and to immediately report any concerns I might have to the Big Brothers Big Sisters staff. 

Type youth's first and last name
Type First and Last Name

CONFIDENTIALITY POLICY 

 

The BBBS of Middle Tennessee respects the confidentiality of all clients’ (defined as caregiver/guardian/parent, child, and volunteer) records and, with the exception of situations listed below, shares information about clients only among the agency professional staff.  In order to provide 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.  It is the agency’s responsibility to protect the confidentiality of reference responses and counseling reports by not disclosing their content to a client applicant.  Therefore, the agency may decide not to disclose the reason for rejection to the client.   

 

All records are considered the property of the agency and not the agency workers or clients themselves.  Records are not available for review by the clients.  Clients must sign this summary statement indicating an understanding of the agency’s confidentiality policy and agree to program participation under the guidelines before being accepted into the program.   

 

Information will be released to other individuals or non-BBBS organizations only with the client's written consent.  Identifying information regarding clients may be used in agency publications or promotional materials unless the client requests otherwise.  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 records.  Members of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors.  Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena.  Information shall be provided to an agency's legal counsel in the event of litigation or potential litigation involving the agency. 

 

State law mandates that suspected child abuse be reported to the appropriate authorities (Tennessee Department of Children’s Services or local law enforcement agency).  If an agency worker receives information indicating that a client may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party.  This may include a medical referral or report to the local law enforcement authorities. 

 

At the time a child or volunteer is considered as a match candidate, information is shared by the agency with the prospective match parties.  The information about the volunteer may include such items as:  age, sex, race, religion, interests, hobbies, marriage, family status, sexual orientation, gender identification, living situation, etc.  Information about the child/parent may include such items as: age, sex, race, religion, interests, hobbies, family situation, sexual orientation, gender identification, living situation etc. 

 

I understand that some information, including opinions of the social worker, may be shared with parents of a potential Little Brother or a Little Sister or a potential volunteer.  I hereby give my authorization for such limited release and use of information that may otherwise be deemed confidential pursuant to the policies contained in the complete confidentiality policy statement and I release and waive any liability against the organization, all Big Brothers Big Sisters personnel and the Board of Directors of said organization.   

 

I have read, received a copy, and understand the above document which summaries the agency policy of confidentiality of client records.  I agree to abide by the conditions it sets forth.   

Type youth's first and last name
Type First and Last Name

MEDIA RELEASE 

 

I grant to Big Brothers Big Sisters of Middle Tennessee the right and permission to copyright and/or publish photographic portraits or pictures in which I may be included in whole or in part of composite or reproductions made through any media or photography for art, advertising, trade or any other similar lawful purpose, including television and product packaging.  

I waive my right to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith.  

I hereby release and hold harmless Big Brothers Big Sisters of Middle Tennessee, its agents, successors and all persons acting under its permission or authority from any liability whatsoever by virtue of any publication, dissemination, or processing.  


I understand that a refusal to consent to the Media Release will have no effect upon my youth's eligibility for services at Big Brothers Big Sisters.  

GRIEVANCE SYSTEM 

  

I understand that should I ever have a concern, complaint, or grievance of any kind, the steps available to me are:

1.    Speak to my assigned BBBSMT contact to discuss specific concerns, complaints, and/or grievances. If after discussion with my BBBSMT contact I feel that my concerns have not been addressed or remedied, then;

2.    Speak with the Vice President of Programs regarding my concerns. If this conversation does not remedy or address my concerns, then:

3.    Speak with the Chief Executive Officer.  

Big Brothers Big Sisters of Middle Tennessee — Technology & Data Consent Agreement  


I acknowledge and consent to the following as part of participation in the Big Brothers Big Sisters (BBBS) program: 


I understand that BBBS utilizes artificial intelligence (AI) technologies and electronic recording tools to assist with processing applications, facilitating the mentor-mentee matching process, and capturing interactions and activities for safety and program development purposes. 


I give my permission for BBBS to use AI systems and electronic recording devices in processing my child’s application. 


I consent to the collection and use of personal data related to both myself and my child, including names, contact information, demographic details, and other relevant information obtained through the application process or during program participation. 


I understand that this data will be used solely to administer the BBBS program and will not be shared with third parties without my explicit consent, except as required by law. 


I acknowledge that BBBS will store this data digitally and retain it only as long as necessary, in compliance with applicable data retention policies. 


I understand that BBBS will take appropriate measures to protect the confidentiality and security of all collected personal data. 

Written Notice of Beneficiary Protections (Title VI)

Big Brothers Big Sisters of Middle Tennessee Mentoring Programs


Title VI of the Civil Rights Act of 1964 reads: “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program or activity receiving federal financial assistance.”

Because this program is supported in whole or in part by financial assistance from the Federal Government, we are required to let you know that:

(1)   We may not discriminate against you on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to attend or participate in a religious practice;

 

(2)   We may not require you to attend or participate in any explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization) that may be offered by our organization, and any participation by you in such activities must be purely voluntary;

 

(3)   We must separate in time or location any privately funded explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization) from activities supported with direct Federal financial assistance; and

 

(4)   You may report violations of these protections, including any denials of services or benefits by an organization, by contacting or filing a written complaint with the Department of Justice's Office of Justice Programs, Office for Civil Rights, 999 North Capitol Street NE, Washington, DC 20531, by email to AskOCR@usdoj.gov, or online at https://www.ojp.gov/program/civil-rights-office/filing-civil-rights-complaint.

(5)   Big Brothers Big Sisters of Middle TN will comply with the Title VI Civil Rights Act of 1964, utilizing its best efforts to maintain compliance in all programs. If you believe that you have been discriminated against because of your race, color, or national origin (including limited English proficiency), by Big Brothers Big Sisters of Middle TN, you may file a formal complaint. Complaints should be directed to Title VI Coordinator, Bridget Heary, at 615-208-7509 or bridget.heary@mentorakid.org

We are required to give this written notice to you before you enroll in the program or receive services from the program, unless the nature of the service provided or exigent circumstances make it impracticable for us to provide such notice before we provide the actual service. In such an instance, we must give this notice to you at the earliest available opportunity.

SCHOOL RELEASE 

 

I give my permission to my youth's school and the Board of Education to release to Big Brothers Big Sisters any information requested for the evaluation of my youth, including directory information from the individual school or system.  I give my consent and permission for my youth’s school and/or the school system to release my youth’s grades and attendance for review or evaluative purposes to Big Brothers Big Sisters. 

If this is not the name of the youth's school, please go back to Page 1 and edit the School field.
Parent/Caregiver Type First and Last Name

Contact Information