Lunch Buddy Student Application

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Lunch Buddy

The Lunch Buddy Program is a FREE program provided by Big Brothers Big Sisters of the Ozarks in cooperation with area public schools.

An adult volunteer (fully background checked) will eat with your child for 30 minutes once a week at the school during your child’s regular lunch period. The role of a Lunch Buddy is to be a friend, mentor, positive role model, and someone who gives your child positive 1 on 1 attention each week during their time together.

The Parent/Guardian will be provided a profile description of the adult volunteer BBBSO has found to meet with your child prior to an introduction meeting with your child.  This information will be sent to you by email and text. If you have any questions, please reach out to us at 417.530.1524. No contact information is allowed to be shared between the Parent/Guardian and the Volunteer.

Bingham           Bowerman       Boyd                      Cowden            Fremont           
Mann                 McGregor             Sunshine         Robberson       
Weller                Williams              Watkins           York
Buchanan Elementary         Cedar Ridge Elementary
Bolivar Intermediate
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. 
Youth Information

Hold CTRL+F to select multiple

Guardian Information
Family Information
Mailing Address
Physical Address

Additional Questions

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

Preferences in a Lunch Buddy Volunteer

We will make every effort to honor your preferences for your child's mentor. You will be notified once we have found a Lunch Buddy for your youth. 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 Lunch Buddy Program;
  2. For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to personally interact with my child;
  3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports, attendance);
  4. To have my child participate in an enrollment interview conducted by Big Brothers Big Sisters staff and complete monthly support visits from BBBSO Staff throughout their time in the program. Interview and monthly support visits contain questions about school, the volunteer they are matched with, home life, 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;
I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process, I understand that the information I provide 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. 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 the Ozarks 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 the Ozarks, 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, and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.

Photo Consent and Release Form

,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 Big Brothers Big Sisters of the Ozarks 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 Brothers Big Sisters of the Ozarks on Big Brothers Big Sisters of the Ozarks' and NATIONAL websites, including,, MatchConnect,, and Big Brothers Big Sisters of the Ozarks COPPA statement is incorporated in the website Privacy Policy here: Big Brothers Big Sisters of the Ozarks 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. 

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 3372 W. Battlefield Springfield MO 65802.

Confidentiality Policy

In order to provide our professional service to our clients, a professional staff member will ask prospective clients to divulge extensive personal information about themselves and their families.  The agency respects the confidentiality of client and volunteer records, and shares information about clients and volunteers only among agency professional staff.  The right to confidentiality applies not only to written records, but also to the publication of clients’ or volunteers’ names, pictures, or other identifying information. 


All records are considered the property of the agency and not the agency workers, clients, or volunteers themselves.  Information received 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 client, parent/guardian, or volunteer. 



1.    Information will be released to other individuals or organizations only upon presentation of an authorized consent to release information form appropriately signed by the client or volunteer. 

2.   Information regarding volunteers or clients will be used in agency publication or promotional materials if the client or volunteer has given permission.

3.   For purposes of agency evaluation, audit, or accreditation, and with approval of our Board of Directors, certain designated persons may review client and volunteer records.  These persons are required to respect the agency policy on confidentiality. 

4.   Members of the Board of Directors have access to client files only upon authorization by formal action of the Board of Directors and only in crisis situations, event of litigation, or possible litigation, or for periodic program evaluation…the Board is required to make a motion that names the authorized person who will review the information and name the specific reason for the review.  The designated person(s) shall be required to comply with the agency policies on confidentiality.  Violation will require removal from the Board. 

5.   Information contained in client and volunteer files shall only be provided to law enforcement officials or the courts, pursuant to a valid and enforceable subpoena.

6.   Law protects confidential information that would be provided to agency’s legal counsel in the event of litigation or potential litigation.

7.   State law mandates that Big Brothers Big Sisters agencies must report any suspected child abuse to the Missouri Division of Family Services. 

8.   If an agency worker receives information indicating that a client or volunteer may be dangerous to himself 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. 

9.   To make a match, profile information is shared between the prospective match parties. Full names are shared with the match mates only after both of the involved parties agree to the match. 

Last consent form, We know it is a lot but BBBSO wants to make sure you have all the information. 

Safety Guidelines, Ground Rules and Expectations

The following ground rules are established to help your child develop a healthy relationship with their Big.

  1. I understand that school attendance is imperative to program successful participation.
  2. I will keep BBBS informed of any changes that may affect the match. If any of my contact information changes I will notify BBBS immediately.
  3. I understand that this is a school based program and all interactions between my child and their Lunch Buddy are only allowed on school grounds in designated areas.
  4. I understand other students are not allowed to participate in my child's one on one time with their Lunch Buddy. 
  5. I understand that a Lunch Buddy provides social & emotional support and that gift giving is not a BBBS requirement of the Big and cannot be requested. 
  6. I understand monthly communication between my child and BBBSO staff is a required element of this program to ensure safety and successful program impact. Communication between my child and BBBS may be facilitated in person at school, by phone or through email. 
  7. I understand that if my child is matched they will remain with the same Big for a minimum of one year but can possibly continue with the same Big until my child leaves the designated school without reapplication. 
  8. I understand that everyone experiences unforeseeable life circumstances that may result in the Big's need to close the match. BBBSO reserves the right to close a match at any time. BBBSO will notify me by email or mail of my child's match closing. 
  9. I acknowledge that my child and I will be provided Safety Awareness training. I acknowledge my role in protecting my child from abuse as discussed in the training provided on the next page of this application. If a problem or concern arises I will notify BBBSO immediately. 

Last page, Next is your signature.