Primary Logo                                                 Child Application

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

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:




















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 Washington County 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 Washington County, 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.

Confidentiality Policy

Access to Confidential Records

 

In order for Big Brothers Big Sisters of Washington County (“Agency”) to provide a responsible and professional service for children, it is necessary for volunteers, children and parents/guardians to be asked to divulge extensive personal information about themselves and their families. Agency respects the confidentiality of the child and volunteer records and, with the exception of the limits of confidentiality listed below, shall not share information about children, parents/guardians and volunteers with any other person outside of Agency, without written consent.

 

All records are considered the property of Agency and not Agency staff, children and parents/guardians, or volunteers themselves. In order to provide a service that 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 children, parents/guardians and volunteers themselves. Records are not available for review by the children, parents/guardians or volunteers. Parents/guardians and volunteers shall be provided, at the time of application, a copy of this Confidentiality Policy, along with the exceptions that define the limits of confidentiality. Parents/guardians and volunteers shall sign a statement that he/she has read and understands Agency’s policy on confidentiality and agrees to program participation under the guidelines it sets forth.

 

Limits of Confidentiality

 

1.   Information will be released to other individuals or organizations upon presentation of an authorized Consent to Release Information, appropriately signed by the parent/guardian or volunteer.

 

2.   Identifying information regarding children and volunteers may be used in Agency’s

publications or promotional materials if the parent/guardian or volunteer has given written permission.

 

3.   For purposes of program evaluation, 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 child and volunteer records. These outside organizations shall be required to respect Agency’s 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’s 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 records, the specific purpose for such review, the period of time required to comply with Agency’s Confidentiality Policy and may use the information only for purposes stated by the approved action of the board of directors. Known violations shall be reported to the board president. A violation of Agency's Confidentiality Policy by a board member shall constitute adequate cause for removal from office.

 

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

 

6.   Information shall be provided to Agency's legal counsel in the event of litigation or potential litigation involving 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 appropriate authorities at the Department of Social Services. All workers are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.

 

8.   If Agency staff receive information indicating that a child or volunteer may be dangerous to himself, herself or 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.

Publicity Release

Thank you for your interest in enrolling your child. Please click the "Submit" button below to electronically sign and officially submit this application, which will begin the enrollment process. A staff member from Big Brothers Big Sisters of Washington County will contact you in the near future regarding additional steps needed in order to complete the enrollment process. 
Save my progress and resume later | Resume a previously saved form

Contact Information