MentorU Summer Mentoring Academy Youth Application & Parent/Guardian Permission Form

Hidden Fields

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Mobile Phone

Best Time to Call

Personal Email

Contact Preference

Employer

Type NA if not employed or currently retired

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing Parish

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

Parish

State

Zip Code

Emergency Contact

Emergency Contact First Name and Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Additional Individuals with Permission to pick up your Little

First and Last Name

Contact Number

Field Trip Permission Acknowledgment

By signing below, I give permission for my child to participate in scheduled field trips:

1. I give permission for my child to attend the scheduled field trips during the Summer Mentoring Academy.

2. I understand that CPSB will provide transpiration; I give permission for my child to ride on the bus for the field trip.

3. I understand my child will be supervised by BBBS SWLA staff for the entire field trip.

4. I understand that my child will need to wear closed-toed walking shoes or tennis shoes and BBBS shirt (provided to them).

5. I understand my child may not be able to participate in the Summer Mentoring Academy scheduled field trips if this form is not signed.

Release of Children:

Big Brothers Big Sisters of Southwest Louisiana maintains a strict policy regarding who is authorized to pick up your child.

In the event of an emergency, BBBS of SWLA staff must be notified by phone as to the name, address, phone number, and brief physical description of the person who will be picking up the Little.

Once the individual arrives at BBBS of SWLA, a staff member will need to verify the individual's identity by reviewing their form of identification- Driver's license, any State or Federal ID- before the child is released. The authorized individual must then sign and note the time of the child's release. Should an unauthorized individual arrive at BBBS of SWLA to pick up the child, a parent or emergency contact person will be immediately notified by phone. If BBBS staff is unable to reach a parent or emergency contact person, the child will not be released. NO EXCEPTIONS.

I agree to program participation under the above conditions, and I request that all persons or agencies accept a photocopy of this authorization to give requested information and/or records.

I accept the terms and conditions

Medical Release

I give permission to BBBS staff to provide or obtain emergency care and transportation for my child if needed. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order and administer medication, injection, anesthesia, X-rays, special procedures, or surgery for my child, if deemed medically necessary. I understand that I am responsible for the cost of any medical care or prescriptions my child requires. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I understand information on this form will be shared on a "need to know" basis with Big Brothers Big Sisters staff.

I agree to authorize medical care. I do NOT agree to authorize medical care.

Confidentiality Policy

BBBS of Southwest Louisiana respects the confidentiality of client and volunteer records and, with the exception of the situations listed below, shares information about clients and volunteers only among the agency professional staff. All records are considered the property of the agency and not the agency workers or clients or volunteers themselves. Records are not available for review by the clients or volunteers.

1. Big Brothers Big Sisters of America and its affiliates will have access to an individual’s information without written consent.

2. Information will be released to other individuals or non-BBBS organizations only with the client’s or volunteer’s written consent.

3. Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteer request otherwise.

4. For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies, such as Big Brothers Big Sisters of America, may have access to client and volunteer records.

5. Members of the Board of Directors or evaluators appointed by the Board shall have access to client files upon authorization of the Board of Directors.

6. Information shall only be provided to the agency’s legal counsel in the event of litigation or potential litigation involving the agency.

7. Information shall only be provided to law enforcement officials or courts pursuant to a valid and enforceable subpoena.

8. State law mandates that suspected child abuse be reported to the State of Louisiana Department of Social Services Office of Community Services Children Youth and Family Services at 800-814-1584.

9. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to local law enforcement authorities.

10. At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. The information shared about the volunteer may include but not be limited to such items as: age, sex, race religion, interests, hobbies, marriage, family status, sexual orientation, living situations, etc. Information about the child may include but not be limited to such items as age, sex, race, religion, interests, hobbies, family situation, etc.

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.

Media Consent

I give my permission for my child’s first name and picture to appear in local advertising for Big Brothers Big Sisters of SWLA. This release covers all advertising including: newspaper, television, radio, agency website, brochures, posters, recruitment booths or any other form of media. I understand that my child may appear on social media with connection to Big Brothers Big Sisters or their Big Sister/Brother. I understand that the volunteer/agency agrees not to use the last name or contact information of my child or provide a link to my child’s profile. I will notify BBBS in any event should I decide to relinquish this permission.

I give permission for my youth’s Big to post pictures or videos of them online or other form of mediaI do NOT give permission for my youth’s Big to post pictures or videos of them online or other form of media.

General Rules and Disciplinary Expectations & Policies

General Rules:

You must sign your child IN and OUT every day- your child may not sign themselves IN or OUT.

1. Snacks and drinks will be provided daily to your child. BBBS of SWLA is not responsible for lunch each day, lunch must be provided by the parent/guardian EXCEPT on designated field trip days or days where lunch is combined with an internal or external activity. Parents/Guardians will be notified of field trip days. We do have refrigeration, a freezer, and a microwave for use onsite.

2. Any personal items brought to the Summer Mentoring Academy are the responsibility of your child. Staff does not assume responsibility for any personal belongings or items. Please label your child's things with their name. Any personal items left at the end of each day will be placed in a Lost and Found box. The Summer Mentoring Academy will not be held responsible for any lost, stolen, or damaged items. This includes cellular phones, tablets/computers, hand-held gaming devices, and all other electronics. It is recommended by BBBS SWLA that all electronic items be left AT HOME to lessen risk of damage, lost, or stolen.

3. Any damage to BBBS of SWLA property caused by participants will be paid for by the participant or their parent/guardians. Items must be replaced before the participant can return.

4. I will drop my child off daily between 7:30am-8:30am. BBBS of SWLA does NOT accept a Summer Mentoring Academy child before 7:30am.

5. I will pick up my child NO LATER than 5:30pm daily; failure to pick your child by 5:30pm MAY result in your child's dismissal from the program. Appropriate accommodations for late pick-up can be arranged before the Academy starts or before the day of, unless and emergency.

6. I understand I must make my own arrangements for the transportation to/from the Summer Mentoring Academy. BBBS SWLA does not provide transportation to/from the Academy.

Disciplinary Expectations & Policies

1. Aggressive and physical behavior, such as fighting, bullying, hitting, biting, etc. toward another participant or staff member WILL NOT BE TOLERATED. Staff members will intervene immediately should this type situation arise.

2. Physical restraint, i.e. a staff member holding a child, will NOT be used

3. Children will be shown positive alternatives rather than being told "no". Parents will be informed if such an incident occurs. If the child's behavior is uncontrollable, extremely disruptive, and/or harmful to themselves or others, a parent will be asked to remove the child from the program immediately.

Participants who do NOT comply with our policy will face the following actions:

1. First Offence/Warning- child's actions will be verbally communicated covering the inappropriate behavior displayed

2. Second Offense- child's actions will be documented and verbally communicated concerning the inappropriate behavior displayed. Child will lose 10 minutes of recreation time, will be asked to sit in a "cool down zone" until proper behavior is restored.

3. Third Offense- child's actions will be documented and verbally communicated concerning the inappropriate behavior displayed. Child will lose an additional 5 minutes of recreation time (in addition to the 10 minutes outlined in Second Offense), will be asked to sit in a "cool down zone" until proper behavior is restored, and will complete a "behavior reflection" form to be signed by their parent/guardian. BBBS staff and parent must sign the document that indicates that a final warning has been issued.

4. Fourth Offense- Grounds for dismissal or expulsion from the Academy.

I have read the above youth safety guidelines and ground rules which define my responsibilities as the parent/guardian of a Little. I agree to abide by them as long as my youth is in the program.