Adult Site Based: Child Enrollment Form

Mentor Program

Which of the following Site-Based facilitated programs are you applying for?

Program ID - IE

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.

Child's First Name

Child's Middle Name

Child's Last Name

Child's Date of Birth

Please include the slashes above.

Gender

How does the child identify?

Race/Ethnicity

School

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School District

School Account ID

Current Grade Level

Student ID

High School Graduation Year

This is the year the child will graduate high school.

Teacher Who Referred You

Will you be the first in your family to attend college?

YesNo

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

Annual Household Income

Number of people supported by this income:

Household Living Situation

Living Situation Description

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Mailing Street Address

Please include unit or apartment #

Mailing City

Mailing State

Mailing Zip Code

Date of Birth

Please include the slashes above.

Age

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

May we contact you at work?

YesNo

Does the child have their own phone?

YesNo

Child's Phone

Parent/Guardian's Relationship to Child

Parent/Guardian's Email

Child's Personal Email

Child's School Email

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Street Address

Emergency Contact City

Emergency Contact State

Emergency Contact Zip Code

Emergency Contact Phone

Emergency Contact Relationship to Child

How did you hear about Big Brothers Big Sisters?

Referral Detail ID - IE

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.

I understand that all information received will be kept confidential, within the agency’s limits of the law. However, California law does require that all professionals who work with families and children under the age of 18 report known and suspected incidents of child abuse, as well as threats of harm to oneself or others. I authorize my child’s school to release the following regularly reported information to Big Brothers Big Sisters of Orange County/Inland Empire on a quarterly basis or as requested, including such information as grade point averages, photocopies of report cards, school attendance rates, grade advancement information, graduation information and noted social and academic information (i.e. relevant behavior reports or counselor/social worker feedback). All identifying information will be held in confidence by BBBSOC/IE staff and volunteers. 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. I give permission: (1) for my child to participate in the Big Brothers Big Sisters of Orange County/Inland Empire Adult Site Based Program; (2) to have my child complete Program questionnaires containing questions about school, home life, and personal interests; (3) to have my child participate in all assessments and evaluations in regards to the Program; (4) to have my child talk with a BBBSOC/IE staff person and a BBBSOC/IE Volunteer about school, home life, personal interests and personal safety; (5) to allow my child to have lunch with his/her Big Brothers Big Sisters of Orange County/Inland Empire Volunteer at my child’s school; and (6) to have my child ride the school bus and participate in group field trips.

I agree to the above policies. I understand that my child is not allowed to meet with his/her mentor outside of the supervised program sessions, BBBSOC/IE or authorized events.

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

School Event Consent

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”), who is participating in the Adult Site Based Program (the “Program”) offered by Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”). I hereby gives my consent for My Child’s Big Brother/Big Sister to attend school related functions in support of My Child, including lunch at the school. I understand that all functions attended will be communicated to Big Brothers Big Sisters Orange County/Inland Empire staff by the Big and that I (parent/guardian) will be contacted to confirm the Big Brother/Big Sisters attendance. I understand that school events are not supervised by Big Brothers Big Sisters of Orange County/Inland Empire.

Initials

2. I do not give my consent to My Child’s Big Brother/Big Sister to attend school related functions in support of My Child.

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

Communication Consent & 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”), who is participating in the Adult Site Based 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, and other Littles or mentees participating in the Program. Such communication may include, without limitation, telephone, text message, email, and video conferencing programs such as Zoom, CommandLink, Google Classroom, and FaceTime. Such communication may also include social media platforms including, without limitation, Instagram, Facebook, Twitter, and TikTok, and online video game platforms including, without limitation, Xbox Live, Nintendo Switch Online, and PlayStation Plus.

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 in 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”) Adult Site Based 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