BBBSGC Youth Enrollment

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PARENTS/GUARDIANS AS PARTNERS

When it comes to the future of our children and the well-being of our communities, we’re all in this together. Parents and guardians are not just part of the process, they’re part of the success.

Not only will you provide information about your child's strengths and needs, but you'll also approve selection of the Big Brother or Big Sister. Once the match is made, you remain closely involved every step of the way throughout the life of the match.

Youth Age Acceptance Policy

For our community-based (traditional) matches, the minimum age for enrollment is 6 and the maximum age is 16. We can start the application process while a child is still 5, as long as he or she turns 6 within a 60 day time frame. While many Big-Little matches continue through high school, we do not take applications for new matches for children who are more than 16 yrs. old.

Hidden Fields

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Youth Information

First Name

Middle Name

Last Name

Preferred Name

Birthdate

Enter a date in the following format: mm/dd/yyyy

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?
School	Graduation Year This is the year the youth will graduate.
School Account ID	Race/Ethnicity Press CTRL while choosing to select multiple

Non-Discrimination & Inclusion Policy

Big Brothers Big Sisters Gulf Coast is committed to the principle of diversity and practices inclusion & non-discrimination, both internally and externally. The agency’s policy and procedures require non-discrimination regardless of race, creed, color, age, religion, sex or gender, gender identity, sexual orientation, national origin, citizenship, , physical or mental health or disability, genetic information or any characteristic protected by law.

All eligibility/acceptance decisions shall be made without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, the presence of a non-related medical condition or disability, or any other characteristic protected by law.

In addition, it is our policy to provide volunteers, guardians and children with service that is free of unlawful harassment of any kind, including that which is sexual, age-related, or ethnic, and any actions which create an intimidating, hostile or offensive environment.

Does the youth have their own phone?

YesNo

Youth's Phone

How would you describe the youth, in terms of participation in events, activities, or sports?

Which activities does the youth enjoy more?

Does the youth have any allergies?

YesNo

Allergies Description

Is the youth taking any medications?

YesNo

Medications Description

Pertinent Medical History

Has the youth ever been involved with the police or juvenile justice system?

What was their involvement?

Guardian's Relationship to Youth

Youth Living Situation

Living Situation Description

Is there a person who shares custody of this youth?

YesNo

Custody is shared with:

Does the youth have a parent/guardian or family member who is currently incarcerated, on parole or probation? If answer YES, complete the Amachi Form, page 2. If answer is NO, go on to page 3.

YesNo

Does the youth have a parent/guardian who is serving or served in the military?

Is the youth's parent/guardian currently deployed?

YesNo

Parent/Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Home Phone

Mobile Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Work Email

Alternate Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

State

Zip Code

Annual Household Income

Is the youth eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

Do you anticipate any significant life changes over the next year, or have you had any in the past year?

YesNo

Life Changes Description

How did you hear about Big Brothers Big Sisters?

Existing Household Members

Please choose this child's relationship to the following people:

Name:	Relationship:
App record ID	contact record ID

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

AMACHI FORM

My child has a relative that is incarcerated, on parole or on probation. Amachi Texas provides funding support to Big Brothers Big Sisters for their mentoring programs for youth in this population.

Information About the Parent/Guardian

First Name

Last Name

Middle Name

Home Address

City

State

Zip Code

Home Phone

Mobile Phone

Gender

FemaleMale

Relationship to Child

Social Security #

Employer

Type NA if unemployed

Employer Street Address

Employer City

Employer State

Employer Zip

Employer Telephone #

Personal Email

Is the child in State custody?

YesNo

Have the mother's and/or father's parental rights been terminated?

YesNo

Inmate Information

First Name

Middle Name

Last Name

Gender

FemaleMale

Relationship to Child

Date of Birth

Status

IncarceratedParoleProbation

Race/Ethnicity

Press CTRL while choosing to select multiple

Education Level (current or highest completed

Inmate's Location

Name of Facility

Facility Address

City/State/Zip

Parent/Caregiver's Authorization for Child Enrollment

I have been provided information on Amachi Texas and wish for my child to be enrolled in the program and be mentored by a Big Brother or Big Sister. I understand that data on my child/family will be collected through surveys and existing records (school and juvenile/criminal justice system), maintained and entered into a secure database during the course of the program. The information will only be utilized for the purposes of tracking services, evaluating the benefits of Amachi Texas for children, and ensuring quality mentoring is being provided. No information will ever be used or reported in any way that can identify my child or family. If I do not want the information entered into the database I may request to sign a separate form stating my objection

I have custody of the child named below and wish to enroll the child in Amachi Texas. My Printed Name serves as my Electronic Signature.

Printed Name of Parent/Caregiver

Date

Parent/Guardian Agreement

In consideration of my child’s participation with Big Brothers Big Sisters Gulf Coast (BBBSGC), I agree to the following:

I agree to support the relationship between my child (Little) and the volunteer (Big) matched with him/her for a period of at least one year. I accept the following Parent/Guardian responsibilities and I will:

Be flexible to accommodate the volunteer’s schedule for seeing my child and help him/her to be ready for scheduled activities, I acknowledge that overnight visits are not permitted;
Encourage my child to contact his/her Big Brother/Sister by phone at least weekly;
Encourage my child to participate with his/her Big Brother/Sister in agency-sponsored activities. If/when his/her Big is unable to participate, I will bring my child to the activities;
Support my child’s Big Brother/Sister in working towards the Case Plan objectives;
Notify my child’s Big Brother/Sister and BBBSGC of any change in address, phone number or living arrangement s as soon as possible;
Contact, and encourage my child to contact, our Match Support Specialist to report on the match bi-weekly for the first month, monthly for the first year of the match, and quarterly thereafter.

I have read and I understand my responsibilities as outlined above and agree to abide by them and support my child and his/her relationship with his Big Brother/Sister throughout the duration of the match between them.

I accept the terms and conditions and give permission for my child to enroll in BBBS.

Medical Release

I grant the volunteer Big Brother/Sister adult matched with my child to have temporary custody and responsibility for the care of the above-name minor, to consent to any X-rays, physical examination, medication, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or surgeon when the need for such treatment is immediate and only after efforts have been made to contact me/us are unsuccessful.

I/We will not hold BBBS, the temporary custodian, physician, or hospital providing care responsible for action taken in good faith in presenting the above named child for care or providing examination. This authorization shall be valid when my child is in the temporary custody and care of the Big Brother or Big Sister or any BBBSGC agency representative or in attendant at any Big Brothers Big Sisters group activity.

I agree to authorize medical care. I do NOT agree to authorize medical care.

Confidentiality Policy

BBBS PARENT/GUARDIAN CONFIDENTIALITY POLICY

Access to Confidential Records

In order for Big Brothers Big Sisters 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. The agency respects the confidentiality of clients 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 not only to written records, but also to video, film, pictures or use of any client or volunteer’s name in agency publications. All records are considered the property of the agency and not the agency workers or 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 the information gained from the clients or volunteers themselves. Records are not available for review by the clients or volunteers. Clients and volunteers are provided, at the time of application, this statement on confidentiality along with the exceptions that define the limits of confidentiality. Clients and volunteers shall sign a statement that he/she has to read and understand the agency policy on confidentiality and agree to program participation under the guidelines it sets forth.

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 or volunteer.
Identifying information regarding clients and volunteers may be used in agency publications or promotional materials 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 the Big Brothers Big Sisters of America may have access to client and volunteer records. These outside organizations shall be required to use the 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.
Members of the Board of Directors have access to client files only upon authorization by formal motion of the Board of Directors. The motion shall state who shall be authorized to review records, the specific purpose for such a review, and the period of time during which access shall be granted. The member shall be required to comply with the agency policies on confidentiality and may use the information only for purposes stated by the approval action of the Board of Directors. Known violations shall be reported to the Board President. A violation of the agency’s confidentiality policy by a Board Member shall constitute adequate cause for removal from office.
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 legal counsel in the event of litigation or potential litigation involving the agency. Such information is considered privileged information and law protects its confidentiality.
State law mandates that suspected child abuse be reported to the appropriate authorities (designated state agency). All agency staff and Volunteers are considered "mandatory reporters" and must report any suspected child abuse and/or neglect. Staff are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.
If any 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 person. This may include a medical referral or a report to local law enforcement authorities.

I have read and understand the above agency Policy with respect to confidentiality of client and volunteer records. I agree to program participation under the conditions it sets forth. I agree to keep information discussed with me regarding a potential (Big Brother/Sister, Little Brother/Sister) match confidential. I will not discuss this information with any person other than the assigned professional staff of the Big Brother Big Sister agency.

I have read and understand the above information provided to me regarding Big Brothers Big Sisters' confidentiality policy. I agree to the conditions set forth.

Social Media Consent

BBBS discourages Volunteers from using Social Media to interact with Littles. BBBS also discourages Volunteers from using Social Media to interact with the Little’s parents, legal guardians, and family members. BBBS encourages Volunteers to interact with their Littles on a one-to-one, in-person basis, which can be arranged via telephone, videophone, text or electronic mail.

If a Volunteer chooses to use Social Media with his or her Little (e.g. by “friending a Little on Facebook”) then both of the following must occur prior to the Volunteer using such Social Media with his or her Little (e.g. prior to extending an invitation or accepting an invitation to friend on Facebook).

The Parent(s) and/or legal guardian of the Little must choose option below, “I give permission…”
The Volunteer must fill out, sign and submit to the Match Support Specialist a Volunteer Online Social Media Disclosure Statement (“Volunteer Disclosure Statement”), which discloses and certifies all of the following:

Site Disclosure.

The Volunteer shall list all the Social Media sites that the Volunteer has, the Social Media sites the Volunteer intends to use with the Little, and the Volunteer’s user name for such sites.

The Volunteer shall certify that the Volunteer has reviewed the terms of use/service and any applicable privacy policy and/or provisions on minors of the Social Media sites that the Volunteer intends to use with the Little, and that the Volunteer is in compliance therewith (e.g. Facebook’s Terms of Service and My Space Terms of Use prohibit use by children under the age of 13 years).

General Privacy Settings.

The Volunteer shall certify that the Volunteer has customized his or her settings on the Social Media sites that he or she intends to use with the Little to ensure that no personal information on the Volunteer’s site is able to be viewed by the general public, without individually granted permission to do so, except for basic information (e.g. name, town, profile picture, and networks).

This type of enhanced privacy setting will help protect the Little by preventing the general public from identifying, searching for or contacting the Little.

Monitoring; Respectful, Legal and Appropriate Content.

The Volunteer shall certify that the Volunteer will monitor the Social Media sites he or she intends to use with the Little (e.g. Facebook page) and those that could be accessed by the Little to ensure that all posts and posted material, whether posted by the Volunteer or a third party, are respectful, legal and appropriate. Further the Volunteer shall certify that the Volunteer will promptly remove any disrespectful, illegal or inappropriate material, or material that could be so perceived by the Little.

Enhanced Restrictions.

The Volunteer shall certify that the Volunteer will consider using Social Media privacy controls and settings to restrict the accessibility of the Little to age appropriate content and content that is respectful, legal and appropriate (e.g. restricting the Little from viewing “wall comments” or restricting “wall comments” altogether).

Discourage Use With Little’s Family.

The Volunteer shall certify that he or she is aware that BBBS discourages Volunteers from using Social Media (e.g. becoming Facebook friends) with the Little’s parents, guardian or family members. BBBS finds this boundary helps guard against requests for match closures by the Little’s parents, guardians or family members based upon extraneous information about the Volunteer via Social Media (e.g. political party affiliation) learned by the Little’s parents, guardian or family members.

Reporting; Health, Safety and Welfare of Little.

The Volunteer shall certify that if he or she views on the Little’s Social Media sites information that endangers the health, safety or welfare of the Little (e.g. information or pictures of the Little engaged in underage alcoholic drinking, drug use, cyber-stalking, cyber-harassing, cyber bullying, or inappropriate sexual behavior, the Volunteer will: (i) report the information to the Match Support Specialist; and (ii) report the information to the Little’s parent(s), legal guardian, or other appropriate person or entity. If it is an emergency, the Volunteer shall call 9-1-1 to report the information and then call the BBBS agency.

General Restrictions.

Finally, the Volunteer shall certify that the Volunteer will comply with Social Media Requirements Governing Volunteers and the Volunteer Social Media Policy.

I give permission for my youth’s Big to post pictures or videos of them online.I do NOT give permission for my youth’s Big to post pictures or videos of them online.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

Child Safety – A Top Priority

Children’s safety is our number one priority. We focus on the child’s safety and well-being throughout the match, not just at the beginning. We want to work together to keep your child safe. While our staff carefully screens each volunteer, we need your help to make sure the relationship is healthy and the volunteer is making good judgments about your child’s safety on outings.

Your approval is necessary for all activities. If you are not comfortable with an activity that the Big suggests, do not approve it and notify your Match Support Specialist .

The Big should never ask your child to keep a secret.

If the following patterns arise, you should discuss them with your Match Support Specialist:

Your child’s Big wants to spend more and more time with your child.
Your child’s Big is frequently buying them gifts.
Your child’s Big often invites other children to join them in activities (siblings, child’s friends, etc.).
Activities always take place in private settings such as the volunteer’s home, instead of more public settings.
Your child’s Big takes an excessive amount of pictures or videos of your child.

We know that you work with your child to teach them skills to help keep them safe. Please feel free to discuss these issues and any other issues related to child safety with your BBBS Match Support Specialist. We want to work with you to keep your child safe.

As a parent/guardian, you recognize the potential of your child better than anyone. By giving them the opportunity to be part of BBBS, you’re starting them down a path to an even brighter, more promising future. We look forward to working with you and your child!

If at any time you have concerns regarding your child’s match, please contact BBBS staff for support.

I have read the above youth safety guidelines and ground rules which define my responsibilities as the parent/guardian of a Little. I agree to abide by them as long as my youth is in the program and I understand that BBBS has the right to close my youth’s match at any time.

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