School Mentoring- Youth Application

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Mission & Program Overview

MISSION:

To create and support one-to-one mentoring relationships that ignite the power and promise of youth.



THANK YOU for applying to be a part of our School mentoring program!


Non-Discrimination Policy
Hidden Fields
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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. 
Youth Information
Enter a date in the following format: mm/dd/yyyy
This is the year the youth will graduate.
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

Additional Information About Your Child


In the Past Year

Medical Information and Release


I authorize Big Brothers Big Sisters of San Luis Obispo County (staff and/or volunteers) to obtain medical and/or surgical treatment for my child in case of illness, accident, or any situation that may arise. These medical services are to be performed by the physician entered below or in his/her absence, any licensed medical doctor. I further state that I will not hold Big Brothers Big Sisters of San Luis Obispo County liable in case of illness, accident, or emergency situation.
Emergency Care Preferences (optional)

Parent/Guardian Agreement & Understanding of Responsibilities

By enrolling my child in this program, we are making a commitment to my child being at program every week. Barring illness, I will ensure my child attends all meetings with his/her Big.


I will consider the volunteer and program when scheduling appointments, sports, etc. and will avoid making afternoon appointments that conflict with my child’s attendance.


I will contact the School Based Specialist if my child is unable to attend program that day.


My child’s Big’s role is to be a friend and mentor during the program; therefore, I will not ask the Big to babysit or engage in non-program activities with my child.


I give permission for my child to complete surveys and an interview containing questions about school, safety, home life, and personal interests and to have my child talk with Big Brothers Big Sisters staff about personal safety.


I give permission for BBBS staff to sign my child out of his/her after-school program.

I may learn sensitive information about my child's Big.  I will keep that information confidential.


I will not deprive the child of weekly visits with the Big as a means of discipline. I understand that this damages their relationship and alienates the Big.


I have a working phone and check it regularly. I will respond to BBBS texts and calls within 48 hours.


I will inform Big Brothers Big Sisters if a problem arises in my child’s match, my contact information changes, or if my child’s availability changes. 

Confidentiality Policy

In order for BIG BROTHERS BIG SISTERS OF SAN LUIS OBISPO COUNTY to provide a responsible and professional service to clients, it is necessary for volunteers, clients, and parents (or guardians) of clients to be asked to divulge extensive personal information about themselves and their families.  This agency respects the confidentiality of client and volunteer records, and with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.  The right to confidentiality applies to written records, video, film, social media (including, but not limited to the internet, networking sites, blogs and personal websites),  photos, and/or any other depiction of the name, likeness, or other description of a client or volunteer in any publication or promotional material.  

           

All records are considered the property of the agency and not the agency workers, clients, or volunteers themselves.  In order to provide a 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 or volunteers themselves.  Records are not available for review by the clients or volunteers.  

           

When a Client/Volunteer is considered for a match, information is shared between the prospective parties.  Each party has the right to refuse the proposed match based on the information provided.  Prior to a match being made, information shared may include but is not limited to: first name, age, sex, race, religion, education, interests, hobbies, marriage and family status, sexual orientation, reasons for applying to the program, and a summary of the reasons an individual was chosen for the match.  The individuals to whom the information is provided shall agree not to share the information with any other person.  For the duration of the match and after formal closure, confidentiality is to be maintained by all program participants.

 

Limits of Confidentiality

Information will be released to other individuals or organizations only upon presentation of an authorized "consent to release information" form appropriately signed by the client, client's representative, or volunteer, except in the instance of suspected child abuse.

 

Identifying information regarding clients and volunteers may be used in agency publications or promotional materials only if the client or volunteer has given permission.

 

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 and volunteer records.  These outside organizations shall be required to respect the agency policy on confidentiality.  Outside parties shall be required to use information only for the purpose(s) stated in the approval action of the Board of Directors.  Known violations of agency confidentiality policy will be reported to the supervisor of the individual involved, and appropriate disciplinary action shall be requested.

 

Directors of the Board shall be required to comply with the agency policies on confidentiality and may use the information divulged to them only for purposes stated by the approved action of the Board of Directors. 

 

Violations shall be reported to the Board President. A violation of the agency's confidentiality policy by a Director shall constitute adequate cause for removal from office.

 

Any subpoena requesting confidential information received by or served upon the agency shall be immediately delivered to the agency's legal counsel for review and appropriate action.  Only the agency's legal counsel shall have authority to determine whether or not any subpoena served on the agency is valid and/or unenforceable. 

 

Information shall be provided to an agency's legal counsel in the event of litigation or potential litigation involving the agency.  Such information is considered privileged material, and communications between the agency and its counsel are protected by confidentiality law. 

 

State law mandates that suspected child abuse and neglect be reported to the appropriate authorities. All workers are responsible for staying abreast of California reporting requirements and shall always comply with mandated procedures.

 

If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party or parties. This may include a medical referral or a report to the local law enforcement authorities.

 

A known violation of BBBS’s Confidentiality Policy shall result in disciplinary action.  Depending on the seriousness of the violation, the action may be a written warning, suspension or termination of the match and/or employment.

Social Media Guidelines for School Based Bigs & Littles

It is very important to respect and maintain child safety, confidentiality, and privacy for all parties in the match.


Under no circumstance is social networking allowed with High School Bigs and their Littles.


If Bigs post about being a volunteer with BBBS, that post may not contain any information about their Little, including but not limited to their Little’s name, description, or parent/guardian information. Bigs must never post any pictures of Littles online.


Big Brothers Big Sisters has the right to monitor the social media activities of our Bigs and other volunteers. If volunteers are discovered to be using social media inappropriately, the relationship between the Big and our organization could be terminated.


If you have any questions about this policy, please speak to the School Based Coordinator. 

Consent and Release for Use of Image

I hereby accept the invitation of Big Brothers Big Sisters of San Luis Obispo County for my child to appear and be identified in print in any Big Brothers Big Sisters of San Luis Obispo County publication or production, or grant the right to use my child's image as specified below.

 

I hereby grant to Big Brothers Big Sisters of San Luis Obispo County and its affiliates the right to use this image, name, and biographical information as they may desire, in all media and in all forms including, but not limited to, publications, any televised photography and recordings. Examples include, but are not limited to, print news media, televised news media, promotional print media and website.

 

I hereby grant to Big Brothers Big Sisters of San Luis Obispo County and its affiliates the absolute right to use this image made through Big Brothers Big Sisters of San Luis Obispo County 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, business, trade, or any other lawful purpose whatsoever, in perpetuum.

 

I hereby release Big Brothers Big Sisters of San Luis Obispo County and its affiliates from all claims, demands or liabilities and related financial costs that may now or hereafter arise in connection with Big Brothers Big Sisters of San Luis Obispo County's exercise of the right hereby granted, with my child's appearance in any publication or production. These include, without limitation, claims for compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever. 

Child Safety

Children and volunteers are not allowed to meet outside of the supervised mentoring program.


Social networking (Facebook, Instagram, Twitter, etc.), online gaming (Xbox, etc.), and video chatting between Bigs and Littles is strictly prohibited. Bigs are to set their profiles to “private” so that the Littles cannot view personal information. Bigs agree to not post anything or share any information about their Little online anywhere.


Volunteers are not allowed to transport children in their cars.


Listen to your child. Ask about the program and your child’s mentor. Contact the School Based Specialist if your child tells you he/she does not want to attend anymore or spend time with the Big.


Teach your children that they have the right to say “no” to any unwelcome, uncomfortable, or confusing touch or actions and to get out of those situations as quickly as possible.


Big Brothers Big Sisters staff is mandated by the state of California to report any suspicions of and/or incidents of abuse or neglect. 

Parent Permission to Participate

  1. I hereby give my permission for my child to participate in the Big Brothers Big Sisters of San Luis Obispo County School Based Program through 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/college mentor. The mentoring will take place every weekly throughout the school year.

  3. I hereby release Big Brothers Big Sisters of San Luis Obispo County and my child’s elementary school of liability during my child’s participation in this program.

  4. I understand that in order for my child to participate in this program, my child will be interviewed for readiness and that all information obtained through this application process is the sole property of Big Brothers Big Sisters of San Luis Obispo County.

  5. I understand that my child will be photographed by Big Brothers Big Sisters of San Luis Obispo County; this is for identification purposes only. This is separate from the Consent & Release to use image (previous pages).

  6. I understand that all information received will be kept confidential, within the agency’s limits of the law. 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 and neglect, as well as threats of harm to self or others.

  7. I understand that I may be contacted via text, email, or mail by Big Brothers Big Sisters of San Luis Obispo County staff to discuss my child’s participation in the program, and that I must reply to any contact from Big Brothers Big Sisters of San Luis Obispo County staff within no more than 3 days.

  8. I understand that Big Brothers Big Sisters of San Luis Obispo County may require access to my child’s school records for the purpose of program evaluation. I hereby permit Big Brothers Big Sisters of San Luis Obispo to access my child’s grades, attendance, and other school records as necessary.

  9. I give permission for Big Brothers Big Sisters staff to talk with my child about personal safety. I have reviewed the child safety information and program guidelines provided to me by Big Brothers Big Sisters of San Luis Obispo County staff. 

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