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? [Must be an adult other than yourself]

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 the Greater Sacramento Area 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 Greater Sacramento Area, 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

Publicity and promotional materials for Big Brothers Big Sisters are conducted in a variety of forms.  May we use your child's name, image, likeness, appearance, or basic biographical information in these materials?
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 [BBBSA affiliate] 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. 

 

Consent for Services
I, 
the parent or legal guardian of
understand and agree with the aim and purpose of Big Brothers Big Sisters of the Greater Sacramento (“BBBS”) and hereby give consent for agency services.
Release of Information and Volunteer Participation

I agree to have released, as needed, to potential volunteer Big Brother/Big Sister, information relating to my child, including contact information.  I authorize BBBS to obtain from my child’s school any social and academic information relating to my child, including report cards and behavior reports.  I also understand that BBBS may share information relating to my child with my child’s school or partnership agencies when applicable.  I further consent to my child’s participation in an in-take interview conducted by BBBS staff, as well as participation in questionnaires throughout his/her time in the program, including questions about school, home life, and personal interests.  I also agree to my child discussing personal safety with any BBBS staff member.   

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 and with exceptions noted.  I understand that incidents of child abuse or neglect, past or present, must 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).

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 BBBS, communicating with BBBS staff as outlined in the 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 BBBS staff.

BBBS Activities and Medical Consent 

I further give consent for my child to accompany a volunteer, assigned by agency staff, on BBBS outings.  The volunteer matched with my child may transport my child to events and match activities.  This form also authorizes the performance of necessary medical and/or surgical treatment of my child in case of illness or accident when neither parent can be located while on these outings.  
These medical services are to be performed by 
M.D.,
telephone #
or in the absence of this doctor, by any licensed medical doctor.  
Media Rights 

I also consent to, and authorize, the reproduction and use by BBBS, or anyone authorized by same, of my child’s name, voice, likeness, and/or photograph in any of BBBS’s publications or promotional materials, including online and in print.  This includes all negatives, positives, slides, video, and/or media. Any or all of the aforementioned shall constitute the exclusive property of BBBS, and I shall not receive any compensation for the use or reproduction of such materials. 

Waiver of Liability and Certification 

I agree to waive, release, hold harmless and promise to indemnify and not sue BBBS, its agents, officers, directors, employees, members, or volunteers for any and all liability, including costs, expenses, and attorneys’ fees, for negligence, personal injury, property damage, or any other claims arising from my child’s participation in BBBS activities.    

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.
Parent Guidelines and Ground Rules
1. Although it is wonderful when a great volunteer feels like an extension of your family, please remember that the relationship that exists is between your child (“Little”) and the Big Brother or Big Sister (“Big”).  Do not ask the Big to take other family members on outings with the Little.

2. The purpose of your child’s Big is not to provide non-outing related transportation, to discipline your child, to be a gift-giver or to provide babysitting services to you.  Please do not treat him or her as such.

3. Activities of your child and the volunteer are to take place away from your home.  All activities are to have your approval in advance.

4. The volunteer does not assume parental responsibility.  Problems in the home, school and community continue to be the responsibility of the parent.  These problems, as well as other family problems, should first be discussed with the Match Support Specialist and then perhaps with the volunteer if appropriate.

5. Have your child ready when the Big arrives.  You should know each time your child and his or her Big go on an outing together, and know where they are going and approximately when they expect to return.  Please make a point of being home when they return.

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

7. The volunteer can most effectively help your child as a friend, rather than as an authority figure.  The volunteer cannot make your child behave by his or her presence, but can help your child want to behave through building the friendship.

8. Be flexible and remember the Big has a busy schedule too.  Be patient if the Big makes any oversights.  The Big is a trained volunteer but is not perfect and is still learning about the relationship, just as you and your child are.

9. Do not deprive the child of a visit with the Big as a means of discipline.  The volunteer cannot build a friendship or help guide your child if they cannot spend time with him or her.

10. Get to know your child’s Big to the degree that you feel comfortable with.  Give the relationship time to develop.

11. Try to let the volunteer know that his or her efforts are appreciated.  Help your child be considerate (i.e. remembering birthdays, making occasional phone calls, etc.).

12. You and your child are expected to discuss problems with the staff and sincerely work out solutions.

13. Your feelings and observations are important to us in evaluating the effectiveness of the friendship between your child and the Big, and in determining how the staff can support you and make the best use of our service.

14. If there is anything about the relationship that concerns you, contact your Match Support Specialist immediately.  The volunteer is also required to discuss any concerns with the Match Support Specialist, especially as it relates to child safety and/or abuse prevention.

15. All major decisions regarding the match relationship should be discussed with your Match Support Specialist.  Big Brothers Big Sisters services are a team effort!
Authorization to Release and Receive Counseling Report

I have applied to Big Brothers Big Sisters of the Greater Sacramento Area for my child to be matched with a Big Brother or Big Sister. I hereby give my consent for:

Please enter the COUNSELOR/THERAPIST'S name
Please enter the COUNSELOR/THERAPIST'S phone number
Please enter the COUNSELOR/THERAPIST'S email

To release, receive from or exchange information with to Big Brothers Big Sisters of the Greater Sacramento Area for the purposes of initial evaluation, support and match retention.

 

This consent authorizes the release of any information requested by Big Brothers Big Sisters of the Greater Sacramento Area including the results of any psychological evaluation, school records, and social or medical history on record concerning me and/or my child. Information that is used Big Brothers Big Sisters of the Greater Sacramento Area outcomes may be shared with funders.

 

In order to establish and maintain a match, Big Brothers Big Sisters of the Greater Sacramento Area shares relevant information about the child and family with the volunteer and about the volunteer with the child and parent or guardian. New information that arises subsequent to the match start date may be shared with the match participants if deemed necessary by the professional staff Information shall be kept confidential between the match parties and the professional staff of Big Brothers Big Sisters of the Greater Sacramento Area.

 

This authorization shall be effective until my child is terminated from the Big Brothers Big Sisters of the Greater Sacramento Area program.

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