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

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 Northeast AL 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 Northeast AL, 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

Big Brothers Big Sisters enjoy sharing our program success stories and match news.  We need parent/guardian permission to share success stories and pictures publicly. Big Brothers Big Sisters is dedicated to serving the best interest of our youth and volunteers enrolled in our mentoring programs. As a policy our agency does not share the last name of our program youth in publications without specific authorization.   

I,
, legal parent or guardian of
, give Big Brothers Big Sisters of Northeast AL permission to feature my child in the following publications/media outlets:
Child's Name

Page 5

Consent to Share Match Information
I am aware of the summary of the information about me prepared by Big Brothers Big Sisters of Northeast Alabama, and consent to its disclosure to a potential match mate.  I understand that I will not be identified by name until after the match has been agreed upon.  I give my permission for the matching summary information to be shared with a potential match mate only under the above conditions.  This consent expires one year from the date indicated below, or at the time a match is formalized, whichever comes first.
Agreement to Protect the Confidentiality of Match Information 

I agree to keep information discussed with me regarding a potential match mate confidential.  I will not discuss this information with any other person other than the assigned professional staff of the Big Brothers Big Sisters Agency.

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 Northeast AL on 
Big Brothers Big Sisters of Northeast AL and NATIONAL websites, including Big Brothers Big Sisters of Northeast AL, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of Northeast AL 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 256-546-5079.

Medical Release

I give Big Brothers Big Sisters of Northeast Alabama and other partnering organizations permission to secure medical treatment for my child in the event of an emergency.  Parent/Guardian of emergency contact person will be notified immediately.

Confidentiality Policy

In order for BBBS of Northeast Alabama to provide a responsible and professional service to clients, it is necessary for volunteers, clients, and parents/guardians of clients 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 situation 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 the use of client or volunteer’s name in agency publications.

 

All records are considered the property of the agency, and not of agency workers, or clients, or the volunteers themselves.  In order to provide a service, which is in the best interest of the children served in 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.  Clients and volunteers shall provide at the time of application, a copy of this statement on confidentiality, along with the exceptions which define the limits of confidentiality.  Clients and volunteers shall sign a statement that they have read and understand the agency policy on confidentiality, and that they agree to program participation under the guidelines it sets forth.

 

 Limits of Confidentiality

1.       Information will be released to other individuals or organizations only upon presentation of an authorized Consent to Release Information Form, appropriately filled out and signed by client or volunteer.

 

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

 

3.       For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies, such as BBBS of America, may have access to client and volunteer records.  The outside organization 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 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.

 

4.       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 the records, the specific purpose for such review and the period of time during which access shall be granted.  Members shall be required to comply with the agency policies on confidentiality and may use the information only for the purpose stated by the approved action of the Board of Directors.  Know violation shall be reported to the Board President.  A violation of the agency’s confidentiality policy by a Board Member shall constitute an adequate cause for removal from office.

 

5.       Information shall only be provided to law enforcement officials for the courts, pursuant to a valid and enforceable subpoena.

 

6.       Information shall be provided to any agency’s legal counsel in the event of litigation of potential litigation involving the agency.  Such information is considered privileged information, and its confidentiality is protected by law.

 

7.       State law mandates that suspected child abuse be reported to the Department of Human Resources.  All workers are responsible for staying abreast of such reporting requirements in their respective jurisdictions, and shall always comply with mandated procedures.

 

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

 


Youth Safety Guidelines and Grounds Rules for Parents/Guardians


  1. Your child’s Big Brother/Sister is NOT a taxicab service, Santa Claus, or a baby-sitter.  Please don’t treat him or her as such.

 

  1. Please don’t discuss your child with the Big Brother/Sister in the presence of your child.  If you think there is something he/she should know, call him/her when your child is away.

 

  1. Try to help your child be considerate of the Big Brother/Sister (i.e. remembering birthdays, making special phone calls, etc.) But please do not interfere in their relationship with excessive quizzing and judgments.  This is your child’s relationship.

 

  1. If there is something about the relationship that concerns you, contact your Case Manager immediately.

 

  1. Please update Big Brother/Sister and agency on any changes to your address, phone number, and/or email. Regular contact must be kept in order for the match to stay active under Big Brothers Big Sisters.

 

  1. Try to let the volunteer know, once in a while, that his/her efforts are appreciated.

 

  1. Remember, the relationship that exists is between your child and the Big Brother/Sister.  Don’t ask that siblings or you to be included on outings.

 

  1. Forgive minor mistakes in judgment.  The Big Brother/Sister is not a trained professional -nor is he/she perfect.  You will probably disagree with the volunteer sometimes.

 

  1. The parent/guardian should not deprive the child of visitations with the Big Brother/Sister as a means of discipline.

 

  1. As the Big Brother/Sister will be telling you when he/she will be returning your child, make a point of being home.

 

  1. Be flexible.  Remember the Big Brother/Sister has a busy schedule too!!

 

  1. Give it time.  This relationship needs time to develop (at least three months), so don’t judge quickly.

 

  1. Your child’s Big Brother/Sister is a person too.  Get to know him/her at least to the degree that you feel comfortable with him/her.

 

  1. No overnight visit should be planned within the first 2 years of match or older.


Assumption of Risk and Release of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing.

Big Brothers Big Sisters of Northeast AL (BBBSNEAL) has provided the following guidance to match parties in an effort to reduce the spread of COVID-19:

  • ·         Restricted match activities to virtual platforms from March 17, 2020 through May 31, 2020.
  • ·         After May 31, 2020, encouraged match activities at a social distance when possible.
  • ·         After May 31, 2020, discouraged match activities that include additional individuals as well as crowded or populated venues.
  • ·         Strongly discouraged any in person match contact if any party has been in contact with an individual known to have COVID-19 or who is experiencing symptoms such as a fever, dry cough, difficulty breathing, etc.
  • ·         Strongly discouraged in person match contact if any party is a frontline worker who could have been exposed to COVID-19 through their profession.
  • ·         Follow the most current CDC guidelines which recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain.

Even with the above measures in place, BBBSNEAL cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, permitting contact between match parties could increase your risk and your child(ren)’s risk of contracting COVID-19.    By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by permitting my child(ren) to participate in in-person match activities and that such exposure or infection may result in personal injury, illness, permanent disability, and in the worst case death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, BBBSNEAL employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s participation in BBBSNEAL program activities. The decision to re-engage in in-person meetings with my child(ren)’s mentor is my decision, not the decision of BBBSNEAL.
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