Youth Enrollment Form

Welcome!

Steps for Youth Enrollment

Watch the Parent/Guardian Orientation video and complete a short questionnaire (10-15 mins)
Complete the Your Child's Personal Safety training (60 mins)
Complete the youth application (5-10 mins per child)
Schedule an interview with us for you and your child(ren) (2-3 mins)

Important Note

**Please be sure to check your primary AND junk email folders for any follow-up material from BBBSM, FormAssembly, or Acuity Scheduling after completing each step of the enrollment process.**

Pre-Screen Questions

Is this youth in the foster care system?

YesNo

Is this youth between the ages of 7 and 15?

YesNo

Unfortunately, we are unable to continue with the enrollment of this youth. Our program requires youth in foster care to be 7-15 years of age when enrolling.

Please contact our Director of Enrollment, Siobhan, if you have any questions or concerns at 402-905-3344 or sfitzgibbon@bbbsomaha.org.

Is this youth between the ages of 7 and 14?

YesNo

Thank you! Please proceed to the next page.

Unfortunately, we are unable to continue with the enrollment of this youth. Our program requires those enrolling to be 7-14 years of age.

To hear about other local mentoring programs, please contact our Director of Enrollment, Siobhan, if you have any questions or concerns at 402-905-3344 or sfitzgibbon@bbbsomaha.org.

To enroll this youth, please complete our inquiry form:

CLICK HERE

You may contact our Foster Care Enrollment Coordinator, Amber, if you have any questions or concerns at 402-905-3353 or amignosa@bbbsomaha.org.

Parent/Guardian Orientation

Thank you for your interest in learning more about joining the Big Brothers Big Sisters' Community-based Program!

Please watch the Parent/Guardian Orientation video and complete the brief questionnaire below it to review what you've learned in the video. Make sure that you find the time and space to do so that will provide you the least amount of distractions.

If you have specific questions about our program or enrollment process, please contact our Director of Enrollment, Siobhan Fitzgibbon, at 402-905-3344 or sfitzgibbon@bbbsomaha.org.

Parent/Guardian Orientation Questionnaire

**Please note that your results may be considered in the acceptance of your child/children.**

Question 1: As the parent/guardian to my child’s match, I am expected to:

Question 2: Which of the following statements is true:

Question 3: How long will it take for my child to be matched?

Question 4: Who do I contact at BBBSM when issues arise in my child's match or I want to share a positive moment between my child and their Big?

Your Child's Personal Safety Training

Course Overview

Nationwide research tells us that children are much more likely to experience violence and victimization than adults. A recent study found that 60% of youth reported having been exposed to violence or victimization in the past year, including sexual victimization. At Big Brothers Big Sisters we are deeply concerned about the safety and well-being of all children - not only in our local programs, but in their daily lives. This course will increase parents’ understanding of the risks of child sexual abuse and how to recognize the signs of abuse better.

Estimated time to complete: 1 hour

Additional Resources

Kid Smartz' Tips for Parents: Safety Scenarios

SSK.org | Guide To Talking To Your Child About Consent

Comments/Questions

Please feel free to share with us any comments/questions you have about this training. Your assigned enrollment coordinator will prepare for and provide information to you on your scheduled interview date, if necessary.

If you would like to speak directly with one of our staff about this training, please contact Kate, our Director of Match Support, at 402-905-3339 or kshanmugam@bbbsomaha.org.

Acknowledgement of Completion

I acknowledge receipt and completion of Your Child's Personal Safety training provided by Big Brothers Big Sisters of the Midlands. In addition, I understand the risks of child sexual abuse and how to recognize the signs of abuse better.

Community-Based Program Agreements

Non-Discrimination Policy and Agreement

Big Brothers Big Sisters of the Midlands will not discriminate against potential volunteers or youth based on race, religion, national origin or citizenship status, gender, gender identity or expression, sexual orientation, disability or marital status.

We, at the agency, expect you will join us in adhering to this policy as an advocate for your child and their potential mentor. We serve a diverse community with individuals from many different backgrounds and values and want to respect those differences as well as protect the safety of our youth, parent/guardians, and volunteers.

I have read the above policy and agree to its terms.

Non-Disclosure Policy and Agreement

BBBSM’s Program staff will communicate with parents/guardians throughout the enrollment and match support process about the importance of BBBS maintaining confidentiality with anything your child may share in order to maintain their trust and safety.

I have read the above policy and agree to its terms.

Parent/Guardian Agreement

As a parent/guardian in the Community-Based Mentoring Program of Big Brothers Big Sisters of the Midlands, I agree to the following: I agree to let my child meet with his/her Big the required 2-4 times per month for a minimum of four (4) hours per month for a minimum of one year.

I agree to maintain open, consistent communication with my child’s Big and Big Brothers Big Sisters of the Midlands staff on a regular basis to ensure the safety of my child, to discuss any concerns or problems and to report any changes I see in my child.

I agree to keep my child’s Big and Big Brothers Big Sisters of the Midlands staff aware of any changes in contact information to ensure the continued support of my child’s match.

I agree to provide money for outings my child has with their Big. If I have any concerns about the amount of money being spent, I will address this with Big Brothers Big Sisters of the Midlands staff immediately.

I agree with the above statements and will do everything I can to help my child develop a positive mentoring friendship with their Big.

Confidentiality Policy Agreement

CLICK HERE TO DOWNLOAD A COPY OF OUR

POLICY ON CONFIDENTIALITY OF RECORDS

I have read and understand Big Brothers Big Sisters of the Midlands’ Policy on Confidentiality of Records (a copy of which I have received above), and I permit participation of my child in the program under the conditions it sets forth. Furthermore, I hereby release Big Brothers Big Sisters of the Midlands (its officers, directors and employees) from any and all claims, damages, causes of actions, liability, cost and expenses (including attorney fees) that I have, or might hereafter have, for the sharing of confidential information in compliance with Big Brothers Big Sisters of the Midlands’ Policy on Confidentiality of Records:

I have read and understand the above information provided to me regarding Big Brothers Big Sisters' confidentiality policy. I agree to the conditions set forth.

Promotional Authorization

I give permission for Big Brothers Big Sisters of the Midlands to use photographs, slides, video tapes, films, television/radio tapings and/or pictures of my child for the purpose of promoting the Big Brothers Big Sisters mentoring program. I also understand that I may revoke this authorization at any time by giving written notice to Big Brothers Big Sisters of the Midlands. Thirty (30) days must be allowed from date of receipt of written notice for revocation to take effect.

Opt InOpt Out

Virtual Platform

Big Brothers Big Sisters of America has developed a digital platform to help Bigs and Littles stay in touch more easily in a safe and secure way. Participation requires your permission.

I consent, should I be matched, to having contact with my Little through Big Brothers Big Sisters' digital platform.

Community-Based Program Agreements (Continued)

By signing this form, I give permission:

1. For my child to participate in Big Brothers Big Sisters of the Midlands’ community based mentoring program;

2. For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to transport my child to events and match activities;

3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (report cards, behavior reports, etc.);

4. To have my child participate in an intake interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program pertaining to topics such as school, home life and personal interests;

5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety; and

6. For Big Brothers Big Sisters 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 information through an in-person interview. I understand that the information I provide during 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 (for example, 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 to the best of my knowledge 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 child’s qualification for this program.

I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating 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 parent/guardian. I understand that this information may be shared with my child’s school or with partnership agencies when applicable.

If my child is matched with a Big Brother, Big Sister or Big Couple, I agree to support my child’s match by reviewing the program and safety information given to me by Big Brothers Big Sisters of the Midlands, communicating with Big Brothers Big Sisters staff as outlined in expectations (which includes communication at least once a month during the first year of the match) and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.

I have read the above agreement which defines my responsibilities as the parent/guardian of a Little. By signing this application, I agree to abide by them as long as my youth is in the program and I understand that BBBS has the right to close my youth’s match at any time.

Girl Scouts Partnership

Girl Scouts Spirit of Nebraska has a partnership with Big Brothers Big Sisters of the Midlands which allows Little Sisters (all grades) to join Girl Scouts and participate in activities and events free of charge! Siblings (kindergarten through 12th grade) can join as well. This applies to all Big Brothers Big Sisters of the Midlands mentees and their siblings in the following counties: Douglas, Sarpy, Cass, Washington, Saunders, Pottawattamie (IA), and Mills (IA).

Through enriching experiences and activities, Girl Scouts discover their values, connect with those who share their vision, and take action to make the world a better place. Girl Scouts is the preeminent leadership development organization for girls, providing abundant opportunities for every girl to do something and be someone amazing!

Girls and their families can choose how to participate, this can be with a troop or as an individual. There are many girls who choose to participate solely by attending programs or a camp. All girls can sell cookies if they desire.

While participating in programs and camps is available at no charge, your girl does need to be registered to participate.

Is this opportunity something that interests the girl(s) in your household?

YesNo

Great to hear!

After you've submitted your Big Brothers Big Sisters application, a representative from Girls Scouts Spirit of Nebraska will contact you within the next month or so for more information on how to get started on registering with them.

No problem!

If you ever change your mind, you can contact us or Girl Scouts Spirit of Nebraska.

Please proceed to the next page.

Additional Enrollments

Each child that you are planning to enroll will need their own application completed. Do you need to submit an application for another child?

YesNo

Next Steps

After completing your e-signature on the next page, you will be re-directed back to a new Youth Application for another child that you would like enrolled in the program. You may click 'Submit' below to proceed.

Next Steps

After completing your e-signature on the next page, you will be re-directed to Acuity Scheduling to set up your interview with us.

Please choose the interview option that best suits the number of children that you are enrolling. You may click 'Submit' below to proceed.

Name:	Relationship:
App record ID	contact record ID