KSBBBS Youth Application

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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 the following format: MM/DD/YYYY
This is the year the youth will graduate.
Press CTRL while choosing to select multiple
CTRL/CMD and click to select multiple
CTRL/CMD and click to select multiple
10 digits, numbers only. This number will not be used for program text messaging, if different from the Guardian's Mobile Phone number below.
Guardian Information
10 Digits, numbers only. I agree to receive communications by text message about my inquiry. Opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy to learn how your data is used.
NO Country Code (i.e., +1) and NO - or () -- Numbers only!
NO Country Code (i.e., +1) and NO - or () -- Numbers only!
Type NA if unemployed
Family Information
Physical Address
Existing Household Members
Please choose this child's relationship to the following people:


Emergency Contact (Other than the Parent/Guardian listed above)
NO Country Code (i.e., 1+) & NO - or ( -- Numbers only!

Acknowledgment and Signature

By signing below, I give permission:


  1. For my youth to participate in the Kansas Big Brothers Big Sisters Program;
  2. For the volunteer matched with my youth, who has been screened and approved by Kansas Big Brothers Big Sisters, to personally interact with and transport my youth to events and match activities, if applicable and allowed by program type. (Community-Based matches only);
  3. For the school to provide social and academic information about my youth to Kansas Big Brothers Big Sisters (e.g. report cards, behavior reports);
  4. For a Kansas Big Brothers Big Sisters staff person to speak with my child at school about their match and overall well-being;
  5. To have my child participate in an intake interview conducted by Kansas Big Brothers Big Sisters staff and complete questionnaires throughout their time in the program containing questions about school, home life, and personal interests to evaluate and improve program services;
  6. To have my youth talk with a Kansas Big Brothers Big Sisters staff person about personal safety;
  7. For Kansas Big Brothers Big Sisters staff to provide contact information for me and my child to the volunteer.

I 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. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law.  I understand that incidents of child abuse or neglect, past or present, will be reported to proper authorities. I understand that 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, on behalf of myself and my child, completely release and forever discharge Kansas Big Brothers Big Sisters and its employees, agents, members, volunteers and all other persons on its behalf, together with any successors in interest, heirs, attorneys, agents, representatives, and all persons acting by, through, under, or in concert with them from all known and unknown charges, complaints, claims, grievances, liabilities, obligations, promises, controversies, damages, actions, causes of action, suits, rights, demands, costs, losses, debts, penalties, fees, wages, attorneys’ fees and costs, and punitive damages of any kind or nature whatsoever, whether known or unknown, which I may have, or may have had, against Kansas Big Brothers Big Sisters, arising from any participation 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 their guardian.  I intend and understand that this release and discharge is to be interpreted and enforced so as to provide the broadest release and discharge possible as may be permitted by law.  I understand that this information may be shared with the 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 in the first year of the match), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.


Parent/Guardian Signature

Type full name in box, enter today's date, click NEXT PAGE when finished.


Photo Consent and Release Form

Parent/Guardian & Minor Child

I,


legal parent or guardian of

irrevocably consent for myself and Minor Child to any and all uses and displays of my or Minor Child’s name, image, likeness, appearance, basic biographical information, audio/video recordings, writings, artwork, and the like, in original form or in modified form, in whole or in part, in, on, or in connection with merchandise, advertising, publicity, marketing, fundraising, and the like, in printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America and Kansas Big Brothers Big Sisters in their sole discretion, and by any of their affiliates, successors, partners, sponsors, donors, any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type, and any other authorized third parties, without further consent from me or Minor Child, without any royalty, payment, or other compensation to me or Minor Child, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use (the “Released Material”).

In consideration of the mutual promises made herein, and for other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I hereby grant to BBBSA and its affiliates the right to use the Released Material as BBBSA and/or its affiliates may desire, in all media now existing or hereafter created and in all variations and forms including, but not limited to, internal or external publications or productions, informational or recruitment materials, marketing materials, fundraising materials, televised photography and/or recordings, advertisements, Public Service Announcements, and/or online and social media sites. The use of this information shall be at the sole discretion of BBBSA and/or its affiliates.

I further grant to BBBSA and its affiliates the absolute right to use the Released Material in whole or in part, alone or in conjunction with any other image, name, writings or reproduction, in color or otherwise, for art, advertising, business, trade, or any other lawful purpose whatsoever, in perpetuity throughout the world.

I understand and agree that all materials created by BBBSA and/or its affiliates that use the Released Materials are the property of and are owned by BBBSA, and that I cannot authorize their use by any other party.  I further understand that BBBSA may authorize their use by a third party. I hereby irrevocably transfer and assign to BBBSA my entire right, title and interest, if any, in and to the Released Materials and all copyrights in the Released Materials arising in any jurisdiction throughout the world, including the right to register and sue to enforce such copyrights against infringers.

I acknowledge and agree that I have no right to review or approve the Released Materials before they are used by BBBSA and/or its affiliates, and that BBBSA has no liability to me or Minor Child for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSA’s and/or its affiliates’ editing, alteration or use of the Released Materials.  BBBSA has no obligation to use the Released Materials or to exercise any rights given by this Consent and Release Form.

I hereby release BBBSA and its affiliates, employees, and agents, as well as any partner companies, from all claims, demands or liabilities and related financial costs that I or Minor Child may now or hereafter have arising in connection with BBBSA’s exercise of the rights hereby granted, and/or with the appearance or the Released Materials 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.

I have read this Consent and Release Form completely. I fully understand what it means, and I agree to its terms. I have not been offered any additional consideration or enticement, nor have I been coerced to sign this document. I am voluntarily signing it for the purposes and considerations described.



COPPA Parental Consent Form

Notice to Parents In compliance with the Children’s Online Privacy Protection Act (COPPA), parents (or legal guardians) of children under 13 years of age must consent to collections, uses and disclosures of the personal information of their children collected by Kansas Big Brothers Big Sisters on Kansas Big Brothers Big Sisters and Big Brothers Big Sisters of America websites, including kansasbigs.org, bbbs.org, MatchConnect, bbbsa.force.com, bbbs.tfaforms.net, forms.bbbs.org and formstack.io. Kansas Big Brothers Big Sisters COPPA statement is incorporated in the website Privacy Policy here: https://www.kansasbigs.org/faq Kansas Big Brothers Big Sisters may have collected your online contact information from your child, as well as the name of the child or the parent, in order to obtain your consent. Your permission is required for the collection, use, or disclosure of your child’s personal information. We will not grant your child access to any BBBS website account unless you provide us with permission. BBBS website accounts provide access to BBBS content, materials, and resources relating to BBBS programs and activities, including information pertaining to matches, etc.

Verifiable Parental Consent

Please print this form, complete it, sign it, scan and email the signed form to info@kansasbigs.org, or mail it to us at Kansas Big Brothers Big Sisters, PO Box 1521, Wichita, KS 67201.



By signing and returning this form to Kansas Big Brothers Big Sisters, you certify that you consent to the collection, use, and/or disclosure of your child's personal information as described in Kansas Big Brother's Big Sister's privacy policy.





You may revoke your consent at any time to refuse further collection and use of your child's information. If you desire to revoke this consent, please write down your revocation of consent and scan and email the signed form to info@kansasbigs.org or mail it to us at Kansas Big Brothers Big Sisters, PO Box 1521, Wichita, KS 67201.
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