Youth Application Template

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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

Hold CTRL+F to select multiple

This is the year the youth will graduate.
Guardian Information
Type NA if unemployed
Family Information

Physical Address
Emergency Contact
If we are unable to reach you, who is someone we could call who always knows how to reach you?

Additional Questions





Other Siblings and Relatives in the Program
Please choose this child's relationship to the following people:




























We will make every effort to honor your preferences for your child's mentor. BBBS does not discriminate on the basis of race, ethnicity, gender, gender presentation, marital status, sexual orientation, or religion.

Parent/Guardian Agreement

By checking the box below and providing my signature at the end of this form, I give permission:
  1. For my child to participate in the Big Brothers Big Sisters Program;
  2. For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to personally interact with and transport my child to events and match activities, if applicable and allowed by program type;
  3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);
  4. To have my child participate in an intake interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout their time in the program containing questions about school, home life, the match, and personal interests to evaluate and improve program services;
  5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
  6. For BBBS 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 Big Brothers Big Sisters of Summit, Medina and Stark Counties 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 Big Brothers Big Sisters of Summit, Medina and Stark Counties , 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.

Photo Consent and Release Form

I,
,legal parent or guardian of
("Minor Child"), 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 [BBBSA affiliate] 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. 

 

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 Big Brothers Big Sisters of Summit, Medina and Stark Counties on BBBS and NATIONAL websites, including MENTORWITHME.ORG, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io.  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.] 

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 contact our agency at (330) 376-6503 or by email at Info@mentorwithme.org

Medical Release


I, give permission for my child, to participate in the Big Brothers Big Sisters of Summit and Median Counties program.  Further, I agree to emergency medical treatment for him/her when regular service cannot be supplied by my own doctor.  In consideration of the above, the undersigned parent releases and discharges Big Brothers Big Sisters of Summit and Medina Counties, its staff, lay officer, volunteers, and agents from all liability in connection with said child’s/ children’s participation in its program and activities.

Confidentiality Policy


CONFIDENTIALITY POLICY

(To be read and signed by agency clients and volunteers)

Access to Confidential Records

In order for BB/BS to provide a responsible and professional service to clients, it is necessary for volunteers, clients, and their parents/guardians to be asked to divulge extensive personal information about themselves and their families. The 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 and with potential matches. The right to confidentiality applies not only to written records, but to video, film, pictures or use of client or volunteer names in agency publications.

All records are considered the property of the agency and not the agency staff, clients, or volunteers themselves. In order to provide agency services, information from outside sources including confidential references, must be assessed along with information gained from the clients or volunteers themselves. Clients, parents/legal guardians, volunteers, board members, Big Brothers Big Sisters of America and its agents shall sign a statement that he/she has read and understands the agency policy on confidentiality and agrees to program participation under the guidelines it sets forth.

Limits of Confidentiality

1.        Except as specified below, information will be released to other individuals or organizations only upon presentation of an authorized “Consent of Release of Information” form appropriately signed by the client or volunteer.

 

2.       Members of the Board of Directors and certain outside bodies such as Big Brothers Big Sisters of America may have access to client files and volunteer records for the purpose of program evaluation, audit, or accreditation. Such persons shall be required to sign a confidentiality statement at the time of access. Known violations of agency confidentiality policy will be reported to the supervisor of the individual involved and disciplinary action shall be requested.

 

3.       Information shall be provided according to law or valid court order.

 

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


Youth Safety Guidelines and Grounds Rules for Parents/Guardians


MATCH AGREEMENT & GROUND RULES

Community Based Program

 

Match Support Team Agreement: The role of the Match Support Specialist (MSS) is to support the match, to monitor the match for safety and healthy relationship development, and to keep the match informed of BBBS events and activities. In order to provide you with the best possible customer service, we agree to these terms:

  • We will be available by phone and email to respond in a timely fashion to any of your needs or concerns.
  • We will professionally monitor and assess your match for healthy development and will assist you if difficulties arise.
  • We will support your progress and identify areas of growth.
  • We will provide ideas and activities for matches to do together every month. These will be low cost, fun and educational.
  • We will offer training opportunities and resources for Volunteers, Parents/Guardians and Littles.
  • We will provide you with a Match Plan at the beginning of the match of the Match and we will work with you to revise the Match Plan at the three and six month anniversary of your match and at least annually thereafter.
  • We will conduct satisfaction surveys and program outcome evaluations, to gain your ongoing feedback of our program.

 

Volunteer Agreement:

  • I will commit to seeing my Little consistently and regularly.  I will not see my Little more than once a week. I will discuss specific circumstances that warrant additional visitation with my MSS.
  • I will initiate contact with my Little by telephone. Match activities will be arranged by me, in advance, and in consultation with the Parent/Guardian.   
  • I will not include other adults and children on outings with my Little without the prior approval of my Match Support Specialist.
  • I will never leave my Little unsupervised or with someone else.
  • I will comply with the BBBS Home Visit and Overnight Policy & Agreement. I will not bring my Little to my home during the first twelve (12) months of my match; and I will not have overnight visits during the first two years.  I understand that overnight visits will be discussed after the match has successfully passed the two year anniversary mark and I have adhered to all of the appropriate terms of the match. I will not discuss home visits or overnights with the Little or the parent before I have had a discussion with the BBBS Match Support Specialist and been given the approval to proceed.  
  • I will plan safe and appropriate activities for my Little.  These activities can be BBBS events or any other free or low-cost activity.  I realize that I am responsible for the cost of any activity that I choose to engage in with my Little. I will keep the money that I spend on our outings to a minimum.
  • I will not give my Little or the Parent/Guardian any money. Gifts for my Little will be limited to birthdays or special holidays, and will not be excessive. 
  • If there are things I need to discuss with the Parent/Guardian, I will do so in private, and not in front of my Little.  If a problem arises between the Parent/Guardian and me, I will contact my Match Support Specialist immediately.
  • I will communicate monthly with my Match Support Specialist and will respond to all phone calls, emails or letters from agency staff.  When requested, I will complete all surveys and evaluations in a timely manner.
  • I understand that I will be required to meet with my MSS and my Little and Parent/Guardian in person at our six and twelve month match anniversary and annually thereafter. I also understand and agree to meet with my MSS, my Little and Parent/Guardian at any time my BBBS MSS feels it is appropriate. I understand that compliance with this policies is required in order to continue my match relationship.
  • I understand I will be responsible for working on my match goals as initially established and being an active participant in setting new goals at the three and six month anniversary of my match and at least annually thereafter.
  • I understand that the following objectives are the overall goals of BBBS and will make every effort to insure that my match relationship with my Little is working toward these objectives.
    1. Successful completion of the 3rd grade reading proficiency tests
    2. Successful completion of the 8th grade math proficiency tests
    3. Graduation from high school and receipt of high school diploma
    4. The development of a 13 year plan that supports education, military service, career training or other activities that will provide for financial independence.
  • When I realize that if/when my match needs to end, I will contact my Match Support Specialist immediately. I understand that I will be actively involved in the closure of my match and I will commit to ending the match in a way that will be best for my Little and myself.


Parent/Guardian Agreement:

  • I agree to let my child see the Big consistently.  I will not allow my child to see the Big more than once a week unless the need has been specifically discussed with my MSS and approved.
  • I understand that I am an active partner in my child’s relationship with a Big Brother/ Sister and that I play an important role in keeping my child safe.
  • I understand that the match is a friendship between my child and the Big. I will not ask for special favors from the Big. My child is the only person who can go on outings with the Big unless my Match Support Specialist gives permission for another adult or child to join the match on an outing.
  • I will be involved in the planning of all match activities and outings but ultimately, I will allow the match to make their final plans.  I will be flexible with family plans so they do not interfere with the match relationship.  If I am not comfortable with a selected activity, I will discuss it with the Big or my Match Support Specialist. 
  • I will contact the Big immediately if my child will not be able to go on a planned outing.
  • I will have my child appropriately dressed, fed, and ready on time for each outing.
  • When my child returns from outings, I will have a detailed discussion with him/her about what the match did together and how the outing went.  
  • I will discourage my child from asking for presents, special treats or expecting expensive outings. I am welcome to send money along with my child on each outing.
  • I will make arrangements with the Big if I cannot be at home when my child is to return from outings.
  • I will return all phone messages/texts/emails from the Big, and will ensure that my child will do so as well.  If there are things I need to discuss with the Big, I will do so in private, and not in front of my child.  If a problem arises between the Big and me, I will contact my Match Support Specialist immediately.
  • I will not use time with the Big as a reward or a punishment for my child. I will not restrict my child from seeing the Big but I may restrict outings to only include educational or service-oriented activities, if necessary.  If I am having difficulties with my child, I will communicate them to the Big and the Match Support Specialist so that a plan for improvement can be developed.   
  • I will communicate regularly with my Match Support Specialist and will respond to all phone calls, emails or letters from agency staff.  When requested, I will complete all surveys and evaluations in a timely manner.
  • I understand that I will be required to meet with my MSS and my child’s Big in person at the six and 12 month anniversary of the match and annually thereafter. I also understand and agree to meet with my MSS and my child’s Big any time my BBBS MSS feels it is appropriate. I understand that compliance with this policy is required in order to continue the match relationship.

 

  • I understand I will be responsible for working with my child and their Big to meet their match goals as initially established and being an active participant in setting new goals at the three and six month anniversary of the match and at least annually thereafter.
  • When I realize that my child’s match needs to end, I will contact my Match Support Specialist as soon as possible. I will end the match in a way that will be best for my child and the Big.

 

Child/Youth Agreement:

  • I agree to see my Big on a regular basis. I will not ask to see my Big more than once a week.
  • I understand that to have a friend I have to be one:
    1. I will talk to my Big and help plan our activities together and I will be open to trying new things.
    2. I will use good manners, always be on my best behavior and will remember to say thank you for outings.
    3. I will be ready on time for our scheduled outings.
    4. I will not ask to bring friends or family members along on activities with my Big.
    5. I will not expect my Big to spend money on me or buy me things.
    6. I will not ask to spend the night at my Big’s house.
    7. I will ask for my Big’s phone number and will try to call/text them.  I will always return calls/texts from my Big immediately.
  • I will always tell my Parent/Guardian about the plans I make with my Big.
  • When I return from an outing with my Big, I will talk to my Parent/Guardian about what my Big and I did together and what I thought (or how I felt) about the outing.
  • I will talk regularly with my Match Support Specialist to tell them about my match.
  • I will not keep secrets about the match from my Parent/Guardian or my Match Support Specialist.
  • I will tell my Parent/Guardian or Match Support Specialist if I am uncomfortable or have a funny feeling about anything that happens with my Big.

 

Ground Rules

1.              CHILD SAFETY

a.     At the beginning of the match, the Parent/Guardian and Big will discuss safety information and family rules. Topics to be discussed should include: family rules or restrictions; parental values regarding music, television shows, & movies; any medical/allergy concerns or needs of the Little; and any other information the Parent/Guardian feels is appropriate. 

b.     During outings, the Big will always keep the Little within “sight and sound.” The Little is NEVER to be unsupervised at any time.

c.     The Big will always respect the Little’s need for privacy and personal boundaries. The Big will always provide a separate, private area for a Little to use the restroom and/or change clothes.

d.     The Big will refrain from any unapproved physical contact, such as wrestling, tickling, hitting, pinching and sitting on a Big’s lap. These behaviors are never allowed.

 

2.            CONTACT WITH YOUR MATCH SUPPORT SPECIALIST

a.        The match will be professionally monitored by BBBS Staff throughout the life of the match.  The Big, Parent/Guardian and Little must stay in regular contact with the Match Support Specialist. This is essential for the development of the match and the safety of the Little.  Contact will occur according to the following schedule:

                                                               i.      After the match introduction, all parties will need to contact the Match Support Specialist within the first 14 days, and again by the end of the first month of the match.

b.       After the first month, all parties will talk to the Match Support Specialist each month.

c.        The Big and the Parent/Guardian will notify the Match Support Specialist immediately if there are any changes in employment, residence or contact information.

 

3.            REPORT OF ABUSE

BBBS is required by law to disclose the following to the appropriate authorities:

a.     If any party of the match is a danger to himself/herself or someone else.

b.     If any party of the match discloses physical, sexual, emotional abuse or neglect.

 

4.            DISCIPLINE  

a.     The Big is a friend, not a Parent/Guardian. It is appropriate for the Big to correct misbehavior within the context of the match relationship. However, parenting is left to the Parent/Guardian.

b.     Physical discipline of the Little by the Big is never allowed. Likewise, any demeaning, shaming, threatening, exploitative behavior is also never permissible. 

c.     The Little is always expected to be on their best behavior when they are with their Big. If the Little does not comply with verbal request(s) made by the Big, the Big will end the outing immediately and return the Little to the Parent/Guardian.

 

5.            VALUES

It is important that all match parties respect the different values and views each brings to the match relationship.

 

6.            MEDICAL TREATMENT

a.     At the beginning of the match, the Parent/Guardian will inform the Big of any special medical issues that the Little has or any medication that the Little takes regularly.

b.     The Big is prohibited from providing and/or administering any medication or medical treatment to the Little. (except in situations where the Little has a life-threatening condition such as food allergies or asthma, and the Parent has granted the Big permission to administer emergency medication, such as an epi-pen or inhaler)

c.     If the Little is injured or needs medical attention, the Big should contact the Parent/Guardian immediately and/or take the Little to the nearest emergency room.

d.     BBBS MSS should be informed immediately of any accident or injury that occurs while the Big is with their Little.

 

7.            SUBSTANCE USAGE 

The Big is prohibited from using or being under the influence of alcohol or drugs while they are with their Little or consuming alcohol within 12 hours prior to picking up the Little. The use of tobacco in the presence of the Little is also strictly prohibited.

 

8.            LEGAL RESPONSIBILITY

The Big assumes no legal responsibility resulting from the relationship with the Little. If a family problem arises, financial or otherwise, the Little or Parent/Guardian may contact BBBS staff for assistance.

 

9.            OBEYING THE LAW

a.     The Big is required to comply with all local, state and federal laws.

b.     Criminal background checks may be conducted on the Big each year that they remain in the program.

c.     The Big is responsible for notifying their Match Support Specialist within 24 hours of the incident of any arrests, convictions and/or traffic violations that occur after the Big is matched.

d.     In addition, the Big will notify their Match Support Specialist if anyone with whom they live is arrested or convicted for any criminal activity, including harm to a child. 

e.     The Big must notify their Match Support Specialist immediately if they choose to obtain a weapon at anytime during the match.

 

10.         AUTO SAFETY

a.     The Big will carry automobile liability insurance as required by the State of Ohio and will submit a current copy of their proof of insurance at the time of enrollment and at least annually thereafter.

b.     Whenever the Big accompanies the Little, the Big must be the driver of the car. At no time is the Little allowed to operate the motor vehicle.

c.     All Littles are required to follow all Ohio and Federal laws regarding riding in an automobile including the use of a car/booster seat or riding in the front or back seat.

d.     Seatbelts will be worn at all times by the volunteer and the Little. For the safety of the Little, it is recommended that any child under the age of 13 sit in the rear of an automobile.

e.     While driving with the Little, the Big will refrain from texting.  Cell phone use is prohibited while driving and cell phone usage in general should be kept to minimum.  The Big should be concentrating their entire attention on the Little.

 

11.           DISREGARD OF GROUND RULES

Any disregard of the above ground rules or any willful misrepresentation of information given to the agency by the Parent/Guardian, Little or Big will result in immediate review and possible closure from the program.

 

I understand and agree to abide by this agreement and the ground rules, policies, and regulations of Big Brothers Big Sisters of Summit, Medina and Stark Counties. Furthermore, I understand that any exceptions must be requested and approved in advance by our Match Support Specialist or a Big Brothers Big Sisters Program Manager. 


Child Application

This part of the application is to be completed by the child

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Contact Information