Youth Application- USE THIS ONE

Non-Discrimination Policy
Our participants come to us with a wide range of personal characteristics. 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

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


  • One-to-one mentoring
  • Children ages 6-14 at time of enrollment
  • Meet 4 hours a month
  • Minimum of 1 year commitment
  • Participate in mutually agreed upon activities
  • One-to-one mentoring
  • Elementary school children
  • Mentors commit to connecting virtually with mentee by reading and responding to exciting reading passages on a secured portal.
  • Adults and high school students welcome to mentor
  • Opportunities to connect with mentee in person or through Zoom quarterly.
  • One-to-one mentoring
  • Mentees are high school students residing in Palm Beach and Martin Counties
  • Mentees attend employability, life skills, and financial literacy workshops
  • Mentees are paired with an adult business mentor
  • Mentors commit to connecting virtually with their mentee and working through a research based curriculum focusing on academic success, preparing for graduation, gaining work experience, preparing for future education and networking
  • Mentees will participate in career exploration opportunities



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 Agreements

  • I hereby make formal application to Big Brothers Big Sisters of Palm Beach & Martin Counties, a non-profit Florida corporation, to make available the services of Big Brothers Big Sisters to my child and, if possible, assign to him/her a competent adult volunteer.
  • I hereby understand that Big Brothers Big Sisters is not obligated to match my child with a mentor, nor are the obligated to provide specific reasons for not accepting my child’s application to receive a mentor.
  • I understand that Big Brothers Big Sisters staff are in compliance with Chapter 39 of the Florida Statutes (F.S.) which mandates that any person who knows, or has reasonable cause to suspect, that a child is abused, neglected, or abandoned by a parent, legal custodian, caregiver, or other person responsible for the child’s welfare shall immediately report such knowledge or suspicion to the Florida Abuse Hotline of the I Department of Children and Families.
  • I hereby release Big Brothers Big Sisters of all responsibilities and liabilities in connection therein.

Policy for Sharing Profile Information

  • In matching a child with a volunteer, the agency will share certain relevant information about the child with the prospective Big Brother or Big Sister. The full name of the child, however, shall remain confidential until after the parent has been introduced to the volunteer. A similar profile of the volunteer will also be shared with the parent or guardian. Any party has the right to refuse to enter into the match based on information communicated.

Authorization Statement

  • I hereby authorize Big Brothers Big Sisters of Palm Beach and Martin Counties to secure information it deems necessary from the following sources: medical records, employers, educational institutions, the military, criminal background records, and any other pertinent sources to evaluate my child’s potential as a program participant of Big Brothers Big Sisters.
Release, Consent and Agreement

I am voluntarily applying for my child and I to enroll for Big Brothers Big Sisters of Palm Beach and Martin Counties.  For this reason, I give the following permission to the agency:


I do hereby authorize representatives of Big Brothers Big Sisters of Palm Beach and Martin Counties to seek and obtain any information regarding myself deemed necessary by them, to provide quality, safe services to children in their programs.  This authorization includes requesting or releasing confidential information from/to the following individuals or agencies:  schools, social services, organizations, therapists, physicians, government agencies.


I understand that this will be considered confidential; and will not be released to other individuals or organizations without my specific consent.  I am aware that this consent will expire when my child concludes services with Big Brothers Big Sisters.  I am also aware that this consent may be revoked by me at any time. My signature indicates that I know what information will be disclosed and the purpose for which it will be used.  My signature also means I have read this form or had it read to me and explained in a language that I can understand.


I agree and consent to the use of profile information in such form and manner as deemed appropriate by Big Brothers Big Sisters of Palm Beach and Martin Counties for recruitment and development purposes.


I hereby release, remise and forever discharge Big Brothers Big Sisters of Palm Beach and Martin Counties, its officers, and employees, successors and assigns from any and all rights of action, liability, demands or claims accruing or to accrue out of this use or resulting from any rights of action, liability, demands or claims relating to libel, slander or invasion of the right of privacy.


I hereby authorize Big Brothers Big Sisters of Palm Beach and Martin Counties to secure information it deems necessary from the following sources: medical records, employers, educational institutions, the military, criminal records, National and State Sexual Offenders and Predators Check, and any other pertinent sources to evaluate my potential as a volunteer. Continued involvement will be based on the information discovered.


Big Brothers Big Sisters of Palm Beach and Martin Counties has the right to accept or deny program participants and is not obligated to match my child with a volunteer. Big Brothers Big Sisters is not required to provide me with a reason my child is not accepted or matched with a volunteer.

Confidentiality Agreement

A.  In order for Big Brothers Big Sisters of Palm Beach and Martin Counties to provide a responsible and professional service, volunteers, children and parents or guardians will be asked to divulge personal information about themselves. The agency respects the confidentiality of client and volunteer records and with the exception of the situations listed below, shares information only among the agency professional staff.

 

1.    For the purpose of program evaluation, audit, or accreditation, certain outside bodies such as Big Brothers Big Sisters of America and grantors, i.e. Children’s Service Council of Martin County, may have access to client or volunteer records.

 

2.   Members of the Board of Directors may have limited and specific access to client files only upon authorization by formal motion of the Board of Directors.

 

3.   Information shall only be provided to law enforcement officials or the courts if subpoenaed.

 

4.   Information shall be provided to the agency’s legal counsel in the event of litigation involving the agency.

 

5.   Suspected child abuse will be reported to the appropriate authorities.

 

6.   If any agency worker receives information indicating that a client or volunteer may be dangerous to himself or others, steps may be taken to protect the appropriate parties.

 

B.   All records are considered the property of the agency.

 

C.   Records are not available for review by clients or volunteers.

Publication/Media Release
Publicity and promotional materials for Big Brothers Big Sisters are conducted in a variety of forms.  By selecting below I authorize Big Brothers Big Sisters to identify me and my child as a participant in the Big Brothers Big Sisters program using my full name.  I also give permission for the use of other forms of media including but not limited to written word, photo, video, social media, and voice recording.

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 Palm Beach and Martin Counties on Big Brothers Big Sisters of Palm Beach and Martin Counties and NATIONAL websites, including mentorbig.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of Palm Beach and Martin Counties COPPA statement is incorporated in the website Privacy Policy here: mentorbig.org. Big Brothers Big Sisters of Palm Beach and Martin Counties 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.

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 in writing.

Child Safety Ground Rules

Prohibited Activities:

    • Overnight Visits
    • Use of Alcohol and Illicit Drugs
    • Non Disclosure of Firearms at enrollment and throughout the life of the match(see Policies/Procedure[i])
    • Non Disclosure of suspected Child Abuse/Neglect  (see Reporting Policy/   Procedure [ii] )

     

    • Transportation
      • Safety Belts
        • Florida law requires the use of seat belts or child restraint devices by drivers of motor vehicles, all front seat passengers and all children riding in a vehicle under 18.
        • Florida’s safety belt law is a primary enforcement law, meaning that an officer can stop a vehicle and issue a citation simply for observing a safety belt or restraint violation.
        • Children should be in the rear seats until at least age 12, since deployed front seat air bags can be dangerous to children.
      • Child Restraints – Car Seats and Booster Seats
        • Florida law requires children age 5 and under to be secured properly in a crash-tested, federally approved child restraint device.
        • Children ages 0 to 3 must be in child restraint devices of a separate carrier or a vehicle manufacturer’s integrated child seat.
        • Children age 4 and 5 must be in a separate carrier, integrated child seat or booster seat.
        • The best child seat is one that fits the child, fits your car and that drivers will use correctly every time.
        • Read the car seat’s instruction manual and the portion of your vehicle’s owner manual when you install a car seat.
        • Remember to check for car seat and booster seat recalls.

    o   School-based & School to Work mentors are prohibited from transporting children.

    o   Only assigned and approved Big should transport Little.

      • Firearms are prohibited in any vehicle that is transporting a Little

     

    • Communication/Parental Approval of all activities
      • Parents/Guardians will be informed and approve all activities in advance.
      • Communication should be open at all times between match parties and agency staff (children should never be asked to keep a secret).
      • Respect for all match parties will be demonstrated at all times.
      • Emergency contact information will be provided and exchanged between match parties and agency staff.

     

    • Limit Setting through Positive Reinforcement
      • Positive limit setting strategies will be outlined based upon the age of the child and any developmental concerns (i.e. ADHD, Special Needs, etc.)
      • Corporal punishment, verbally and/or emotionally abusive means of discipline by Bigs is strictly prohibited and will result in match termination and/or possible reporting of suspected abuse to Florida’s Child Abuse Hotline – if deemed appropriate.
    • Preventing Over-Involvement with the Child and/ or the Child's family
      • Gift Buying should be approved in advance by the parent/guardian and agency staff notified when a gift of an excessive nature is given to a child.
      • Monetary donations or donations for services by the Big to the child’s family should be discussed and approved by the agency’s match support staff in advance.
      • Excessive contact over the agreed upon schedule should be discussed with the agency staff (especially critical in the early stages of a match relationship).
      • Involvement of other children on outings should be discussed in advance with the child’s parent/guardian and agency staff.
    • Interactions between volunteers and children will show respect for privacy and personal boundaries.
      • Children have the right to feel safe at all times.  Appropriate and positive interactions between Bigs and Littles are essential in supporting positive youth development and making youth feel valued.  Conversely, inappropriate or harmful interactions can potentially injure a child physically and/or emotionally.  Maintaining a balanced approach to development and monitoring of the match to ensure adherence to agency ground rules in this area is critical to positive youth development and child safety. 
      • Volunteer will refrain from activities that pose a risk for injury.
      • Agency ground rules surrounding volunteer and child interactions support strategies that help children establish a clear set of personal safety boundaries promoting skill-building that may prevent the child from becoming the victim of violence and/or exploitation (bullying, child sexual abuse, internet exploitation, dating violence, etc.) and/or encourage a child to disclose abuse or victimization.

     

        • Volunteers are encouraged to be sensitive to whether a hug or other form of physical touch would be comfortable to a child or not. School-Based Mentoring must abide by the Code of Conduct of the Palm Beach and Martin Counties School Districts. 
        • Certain types of physical contact such as: tickling, wrestling, pinching, patting, or asking a child to sit on an adult’s lap are more likely to violate a child’s personal boundaries. 
        • Display or discussion of any materials of a sexual nature is strictly prohibited.
        • Volunteers need to provide separate, private areas for a child to: change clothes, bathe, shower and/or nap.
        • Volunteers should never sleep or nap with a child in the same bed, sleeping bag or couch.
        • Volunteers should never come between a parent and their child. Volunteers need to respect a parent’s role and authority.

    [i] The American Academy of Pediatrics and the Center to Prevent Handgun Violence recommends the following safeguards if you keep a gun in your home:  always keep your gun unloaded and locked up;  lock and store bullets in a separate location; make sure children don’t have access to the keys; ask police for advice on safe storage and gun locks; the best way to reduce gun risks is to remove the gun from the home.. (1996, 2nd Edition, Keep Your Family Safe from Firearm Injury).  Agency policy requires that any and all firearms in the home be disclosed to agency staff prior to the match and be fully secured.  Firearms are prohibited in any vehicle during transporting of a Little.    

    [ii] Volunteers and parents are required to communicate openly with agency staff any concerns for a child’s well-being, up to and including reporting any suspected child abuse to agency staff immediately.  State law  requires mandatory reporting by case managers.  Reports to law enforcement and child protection authorities will be handled by agency professional staff, in cooperation with the parties involved. 

    Social Networking Policy

    Big Brothers Big Sisters of Palm Beach and Martin Counties (BBBSPBMC) recognizes online social networking sites (Facebook, Instagram, Twitter, LinkedIn, etc.) are well-known uses of communication and that many of the volunteers and children in our program are using these sites. Although we encourage our Bigs and Littles to be friends in addition to being mentors/mentees, not all social networking sites are appropriate for enhancing those relationships. 

    • The School Based and School to Work Programs does not permit their mentors to engage in social networking with their mentee. (This excludes approved BBBSPBMC virtual mentoring platforms such as iCouldBe and Cricket Together.)
    • The Community Based program mentors must adhere to the following policies if they choose to engage in social networking with their mentee.
    SOCIAL NETWORKING POLICY:
    •Never post the last name of your child's mentor. In addition, do not “tag” your child's mentor in any picture you post.
    •Never post any contact information about your child's mentor or their family (this includes the mentor's home address, place of employment, etc)
    •Never post anything (status, pictures, etc) that could be perceived as judgmental or offensive to your child's mentor. In addition, be mindful of what others post on your personal site.
    •Make sure that your page settings are set to private, so you can select who can view your information.
    •Tell the mentor about anything you post pertaining to your child's mentor and ensure they approve of it.
    •Do not post pictures that include any other child, Little or their Big on your personal page.
    •Refer to social networking site restrictions on communicating/connecting with youth.
    • For example, users under the age of 13 years old are not allowed to sign up for a Facebook account; therefore do not “Friend” your Little on Facebook if he/she is under the age of 13.

    Additional Considerations:

    •Remember to be observant of your child's page, contact your Match Support Specialist if you see anything that is inappropriate or you are concerned about.
    •BBBSPBMC has the right to view the content and assess all public material on the social networking sites utilized by prospective or current Bigs and other volunteers. Inappropriate information or visual material can be cause for non-acceptance as a child or subject for review and potential match closure by BBBSPBMC.
    •Consider making only specific aspects of your site viewable to your mentor. Please reference the privacy settings on your site for more information.

    •If you have any questions please contact your Match Support Specialist and refrain from accepting any invitation until you discuss your concerns with them.

    Parent Consent for School to Work

    Parent Consent for School Based Programs

    Please provide your responses below. Your input is important to us so we may better choose a mentor for your child.
    Please indicate, on a scale of 1 to 5 (5 being the highest) how you would rate your child in the following areas:
    1 (lowest) 2 3 4 5 (highest)

    Signature Page

    Contact Information