Community Based Youth Application

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Community Based Program
Big Brothers Big Sisters of the Ozarks operates under the belief that inherent in every child is incredible potential. We make meaningful, matches between adult volunteers (“Bigs”) and children (“Littles”), 1st grade through young adulthood in our community. We develop positive relationships that empower the promise and potential of children. 

A matches will go on outings together between 2-4 times a month. 






Non-Discrimination Policy
Our participants (Parent/Guardians, Children and Volunteers) 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



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



Parent/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?




Home Life



Examples include moving, job changes, or changes in family size or dynamics.






*Person(s) with Disabilities includes the term "disabled person" and means a person who: (a) has a disability as defined in Section 23 of the Social Security Act;(b) has a physical, mental, or emotional impairment that (1) is expected to be of long-continued duration (b) has a physical, mental, or emotional impairment that (2) substantially impedes his or her ability to live independently,; and (3) is of such a nature that such ability could be improved by more suitable housing conditions; OR (c) has a developmental disability.

School


This is the year the youth will graduate.






Band, Student council, Art classes, Church youth group, Sports, School Clubs, Scouts


Physical & Mental Health









Answering yes to this question will not affect your child's acceptance into Big Brothers Big Sister program


Your Preferences of a Big


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 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, though, 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 (which includes communication at least once a month in the first year of the match and quarterly contacts until the match is closed), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.

Photo 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 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 Sisters of the Ozarks on Big Brothers Big Sisters of the Ozarks and NATIONAL websites, including www.bigbro.com, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of the Ozarks COPPA statement is incorporated in the website Privacy Policy here: https://www.bbbs.org/legal-notices/privacy-policy/  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 ETC.] 

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 417-889-9136 or in writing to 3372 W. Battlefield Springfield MO 65807.
Confidentiality Policy

           I consent to the disclosure of the following information to a potential match for me or for my child.

 

          Volunteers:  Age, sex, race, religion, gender identity, interests, hobbies, martial and family status and background, history of abuse, sexual preference and views, living situation, education and employment, criminal and driving record check, reasons for applying for the program, and a summary of why individual was chosen.

 

                    Child:   Age, sex, race, religion, gender identity, interests, hobbies, family history, status and living situation, history of abuse, school and other agency involvement, a summary of client's needs assessment and expectations for match participation.

 

 

    I understand that I or my child will not be identified by full name until after a match

    has been agreed upon by both parties.  I also understand that I have the right to

    refuse to enter a match based on anonymous information shared. 

 

 

I   I agree to keep information discussed with me regarding a potential (BigBrother/Big

    Sister or Little Brother/Little Sister) match confidential.  I will not discuss this

    information with any person other than the assigned professional staff of the Big

    Brothers Big Sisters agency.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

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

  1.  I will remain within the guidelines of the program I select for my child’s match unless approved by my Match Coordinator and my child’s Big.
  2. I will maintain regular contact with Big Brothers Big Sisters support staff by responding to calls, letters, e-mails and evaluations in a timely manner.  If a problem arises in my child’s match relationship or if any of my contact information changes, I will notify BBBS immediately.
  3. I will notify my child’s Big immediately if plans change before or during a scheduled outing.
  4. I will not allow my child to participate in overnight activities.
  5. I will not allow my child’s siblings or friends to go on match outings with the Big.
  6. I will not allow the Big to hangout at our home for an outing.
  7. I will not ask the Big for special favors.(i.e., babysitting, transportation, fixing things around the house)
  8. I understand that BBBS Staff and Volunteer Bigs are mandated reporters and are required by law to report any suspected child abuse or neglect.
  9. I will have knowledge of all outings between my child and their Big in advance.
  10. I have the right to not approve of an outing in advance of outing engagement.
  11. I will make sure my child is prepared for their scheduled outing with their Big (e.g. fed, appropriately dressed, at the discussed location, on time, etc.)
  12. I will actively participate in the closure procedure as requested by BBBS staff.

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