Mid Michigan BBBS Logo                                                                                                           Youth Application

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Non-Discrimination Policy

All applications will be given equal consideration regardless of race, age, sex, disability, marital status, sexual orientation, gender identity, religion or national origin.  All content is property of Mid Michigan Big Brothers Big Sisters.

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Youth Information





Enter a date in the following format: mm/dd/yyyy





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This is the year the youth will graduate.





Guardian Information




















Type NA if unemployed





Family Information






Physical Address

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.

Medical Release

In the event that I cannot be located at the time of any illness or injury of my child, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental, or surgical diagnosis, or treatment and hospital care from a licensed physician and/or surgeon, as deemed necessary for the safety and welfare of my child.  It is understood that the resulting expenses will be the responsibility of the parent(s) or participant.
Emergency Contact
If we are unable to reach you, who is someone we could call who always knows how to reach you?










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 Mid Michigan Big Brothers Big Sisters 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 Mid Michigan Big Brothers Big Sisters, 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.

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 Mid Michigan Big Brothers Big Sisters 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 on Mid Michigan Big Brothers Big Sisters and BBBS of America websites, including www.bbbsmitten.org, bbbs.org, MatchConnect, bbbsa.force.com, and forms.bbbs.org. Mid Michigan Big Brothers Big Sisters COPPA statement is incorporated in the website Privacy Policy.  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, activities, agency events, and resources. 

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 (989) 386-9304 or info@bbbsmitten.org.

Social Media Guidelines 

“Social Media” is also called “social networking,” but this policy is to provide guidance on Mid Michigan Big Brothers Big Sisters expectations regarding the use of social media by its participants in an appropriate manner.


While Mid Michigan Big Brothers Big Sisters respects your privacy and your right to free speech, you also have responsibilities when you voluntarily put information into the public domain.  If you engage in conduct while using social media, as defined below, that is false, violates MMBBBS policies, is inflammatory, or constitutes violations of the privacy of others, your child could be subject to immediate removal from the program and also personal liability.

Social Media refers to activities that integrate technology, social interaction and the sharing of words, pictures, videos and audio, such as”:

  1. Multimedia and social networking sites like Facebook, Twitter, Instagram, Snapchat, TikTok, YouTube, MySpace, and flickr.
  2. Social networking sites with an emphasis on professional exchange of information and development of business, such as LinkedIn;
  3. Blogs, microblogs, wikis, message boards, social bookmarking Web sites, and other community based sites or collaborative tools;
  4. Social commerce postings; like product or experience reviews and;
  5. Community based websites or selling pages
  6. Any other site where information (test, images, video, sound, or other files) can be uploaded or posted.

As a participant (or Parent/Guardian of a child participant) of Mid Michigan Big Brothers Big Sisters, your actions, speech, and statements whether in person, on the phone, in print, or online are reflective of our organization as a whole.  Before you post information online that relates in any way to MMBBBS or your “Match” please review and become familiar with the following guidelines.

  1. Think before you “send”.  Always remember to think about what you plan to say and how you plan to say it, before composing information and sending it out.  Once it is out there, it is difficult, if not impossible, to take it back, Do not communicate information when you are excited or angry.  You may not like what you sent when your mood has passed.
  2. Keep confidential information confidential.  Any statement, whether made online or offline or through images, videos, or sound files, related to or referencing MMBBBS’s mission, operations, staff, board members, Littles, Volunteers, or matches regardless of the media or form used must be approved by MMBBBS staff in writing.
  3. Be accurate, truthful, and considerate in your posts.  Be constructive, provide appropriate context, and think about the impact of your comments on your match, Little, Volunteer and MMBBBS. Be thoughtful about what your share and how you share it.
  4. Be respectful.  Respect for others is mandatory.  Do not post or share photos of your match, Little or Volunteer or statements about without the written approval of MMBBBS and parent/guardian, Volunteer permission.
  5. No privacy exists.  The internet is fully searchable, which means that anyone with an Internet connection, including your Match, MMBBBS, and the public can find even the most obscure information.  Be careful about posting personal information online, whether it is information about you, your match or MMBBBS.  Personal information includes photos, addresses and telephone numbers, information about where you are or where you have been with your match or anything else that could compromise your safety or that of your match.
  6. Consider possible legal ramifications.  Remember that individuals can be held legally accountable for comments deemed to be defamatory, slanderous, libelous, obscene, or proprietary, whether they pertain to MMBBBS, other organization or to your match, or an individual person.
  7. Identify yourself.  You must make it clear that you are speaking for yourself and not on behalf of the MMBBBS.  Speech that appears to represent MMBBBS, even remotely, takes on the appearance of an official position statement and is not permitted in any circumstance.  MMBBBS’s intellectual property, logos, trademarks, and copyrights may not be used in any manner.
  8. Communicate directly first. Remember that MMBBBS staff, volunteers, and parents/guardians rely on communication to identify and resolve issues.  If you have concerns about your match or MMBBBS procedures or conduct, please first contact staff directly, per signed ground rules, in attempt to resolve the matter.

Community Based                                                                                      Youth Safety Guidelines and Grounds Rules for Parents/Guardians

I UNDERSTAND THAT I MUST BE SUPPORTIVE OF THIS RELATIONSHIP IN ORDER FOR MY CHILD TO BENEFIT AS MUCH AS POSSIBLE, THEREFORE I WILL: 


1.    Help my child be ready for outings on time and be appropriately dressed. 

2.   Make sure that my child is provided with adequate money for his/her outing when appropriate. 

3.   Be flexible about family plans so they do not interfere with the match. 

4.   Not allow my child to visit their Big’s home for the first three months of the match. 

5.   Not allow overnight activities. Requests for exceptional circumstances may be submitted to the caseworker prior to activity for Executive Director consideration and approval.

6.   Not allow email correspondence for the first six months of the match and after six months that I as a parent can make the decision to allow or not to allow email or social media correspondence.

7.   Not use restriction from seeing Big Brother/Big Sister as punishment. 

8.   Not encourage other siblings to participate in their outings. 

9.   Discuss match activities with volunteer prior to the event and refuse participation in any activities I feel are inappropriate. 

10. Child safety is our first concern. Please discuss match activities with child after the fact and show interest. 

11.  Keep regular monthly contact with the agency caseworker by responding to phone calls and letters, being prepared to give feedback to the agency regarding the match. NOTE: we need to talk also to your child about the match.  We may call, visit, or stop by the school to talk to your child. 

12. Keep information discussed with me regarding a match confidential.  I will not discuss this information with any person other than the assigned professional staff of the Big Brothers Big Sisters agency. 

13. Not ask personal favors of the Big Brother/Big Sister and not impose upon the Big Brother/Big Sister for free babysitting. 

14. Keep BBBS advised of any changes to contact information or family dynamics. Ie. Phone number change, marriage, etc.

*    Contact my caseworker immediately if a problem or if I have any concerns about          the match.  

Site Based/Lunch Buddies                                                                                  Youth Safety Guidelines and Grounds Rules for Parents/Guardians

I UNDERSTAND THAT I MUST BE SUPPORTIVE OF THIS RELATIONSHIP IN ORDER FOR MY CHILD TO BENEFIT AS MUCH AS POSSIBLE, THEREFORE I WILL: 


1.   I will not allow contact between my child and their Big Brother/Big Sister outside of school hours unless cleared and approved by BBBS staff.

2.   Not use restriction from seeing Big Brother/Big Sister as punishment.

3.   Notify Big Brothers Big Sisters office if your child is not in school due to illness/vacation etc.

4.   Ask my child about their match and show my interest.

5.   Encourage my child to show appreciation of their Big Brother/Big Sister.

6.   Respond to phone calls/emails/letters from BBBS staff.  I will give feedback about my knowledge of the child’s match.  NOTE: We need to talk also to your child about the match.  We may call, visit, or stop by the school to talk to your child. 

7.   Keep information discussed with me regarding a match confidential.  I will not discuss this information with any person other than the assigned professional staff of the Big Brothers Big Sisters agency. 

8.   Not post or share any statement, photo, video, or sound file relating to BBBS, staff, board members, or volunteers without written approval from BBBS.

9.   Not ask personal favors of the Big Brother/Big Sister.

      10. Not expect Big Brother/Big Sister to buy my child gifts.

      *    Contact my caseworker immediately if a problem or if I have any concerns                about the match.  

Application Acknowledgment

I agree information contained in this application is correct and accurate to the best of my knowledge and I understand that this application constitutes a request to Mid Michigan Big Brothers Big Sisters to involve my child in their program. I realize that Mid Michigan Big Brothers Big Sisters is not obligated to assign, or actively seek to assign, a Big Brother or Sister for my child. I give my permission to release information regarding myself and/or my child to a volunteer Big Brothers Big Sisters has selected for my child. I further understand that I will also have the opportunity to learn about a potential volunteer before a match is made, and that I will have the option not to accept the candidate selected by Mid Michigan Big Brothers Big Sisters. I further understand that Mid Michigan Big Brothers Big Sisters reserves the right to accept or reject my child base on pre-established criteria, and retains the right to close a match at any time without explanation.


For and in consideration of Mid Michigan Big Brothers Big Sisters, Inc., Clare, Michigan, a Michigan Corporation, using their best efforts and monies, and giving freely of their time and efforts and monies to assist my minor child to develop and grow into a worthwhile and wholesome man/woman, I, the mother/father of said minor child, hereby release, acquit and forever discharge Mid Michigan Big Brothers and Big Sisters, a Michigan Corporation, their heirs, members, executors, administrators and assigns, of and from any and all actions, causes of action, claims, demands, costs, expenses and compensations on account of or, in any way, growing out of injuries, loss of any nature or death, by reason of any actions, activities or negligence, excepting gross negligence, of the Mid Michigan Big Brothers and Big Sisters.

 

I further state that I have carefully read the foregoing release and know the contents thereof, and that the terms of this release are contractual and not mere recital.

 

I hereby request and authorize the staff of Mid Michigan Big Brothers Big Sisters, Inc. to release and receive information concerning my minor child from schools, social work and mental health agencies. This authorization shall continue in effect until revoked in writing.

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