Youth 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. 
Referring Agencies
This application must be signed by the parent/guardian of the child being referred. If you are a referring agency that is assisting a P/G to complete this form, please note that BBBSVT will not be able to process the application without the P/G's signature.
Hidden Fields
To look up the owner's email for notifications
For notifications
Youth Information
Enter a date in the following format: mm/dd/yyyy
This is the year the youth will graduate.
Parent/Guardian Information
Type NA if unemployed
Family Information
Physical Address
Existing Household Members
Please choose this child's relationship to the following people:


Emergency Contact

Parent/Guardian Agreement

I DO NOT plan to move from Vermont within the next 12 months.


I AGREE that once the enrollment process has begun, I will respond to emails, phone calls, or text messages from BBBSVT within one week of initial contact, until the match process is complete.


I AGREE to attend all scheduled meetings with BBBS during the enrollment process. I am allowed to reschedule meetings with BBBSVT only one time, during the enrollment process.


I AGREE that after the match is made, I will respond to emails, phone calls, or text messages from the Program Coordinator and my child’s Big within one week of initial contact.


I AGREE that my child’s Big is expected to spend little to no money on my child. I understand that this relationship is about the time spent with my child.



I AGREE that if a problem arises, I will communicate with my Program Coordinator and/or the Big immediately. 

Confidentiality Policy

I agree to keep information discussed with me regarding a potential match (Big Brother, Big Sister) confidential.  Likewise, after a match is made, I will keep confidential any information about the Big Brother, Big Sister, or about that person’s family.  If for any reason the match is not made, I likewise agree to keep the information confidential.  I will not discuss this information with any person other than the assigned professional staff of the Big Brothers Big Sisters program.

MEDIA CONSENT, RELEASE and WAIVER for CHILD



I hereby consent to any and all uses and displays of my 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 Vermont, 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 without any royalty, payment, or other compensation to me, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use.


 

Permission to Participate

I give permission for my child to participate in the Big Brothers Big Sisters Program;  

For the volunteer matched with my child, who has been screened and approved by Big Brothers

Big Sisters, to transport my child to events and match activities (Community-based matches only);

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

To have my child participate in an in-take 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; 

To have my child talk with a Big Brothers Big Sisters staff person about personal safety; 

For BBBS staff to provide contact information for me and my child to the volunteer.

Enrollment Certification


I consent to and understand that: The program is not obligated to match my child with a volunteer and that as part of the enrollment process, I will be asked to provide additional information through an in-person interview.

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.


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 relevant to child-safety and well-being).


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 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 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 my child’s 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 as outlined in expectations (which includes communication at least once a month during the first year of the match and bi-monthly thereafter), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.