Youth Application Template

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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. 
Important Message
**Please be sure to check your primary AND junk/ spam email folders for any follow-up material from BBBSBC, FormAssembly, or MatchForce after completing each step of the enrollment process.**
Age Requirement
Unfortunately, we are unable to continue with the enrollment of this youth. Our program requires youth be between the ages of 7-15 years when enrolling.

Please contact our Program Director, Christina Roebuck, if you have any questions or concerns at 215.343.8260 x105 or email: CrRoebuck@bbbsbc.org.
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?

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 [Agency Name] 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 [Agency Name], 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

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 BBBSBC 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. 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 BBBSBC on BBBSBC and NATIONAL websites, including BBBSBC.ORG, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. BBBSBC 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 our matches and other confidential information. 

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 PROGRAMS@BBBSBC.ORG.

Medical Release

CONSENT FOR EMERGENCY MEDICAL CARE


 I                                                                                                                               hereby give my consent for emergency medical/surgical/dental care and treatment necessary in the opinion of the volunteer or medical personnel to preserve the health of my child while he/she is with his/her Big Brother/Big Sister or participating in an event sponsored by Big Brothers Big Sisters of Bucks County, Inc. I also consent to emergency transportation by ambulance to appropriate medical facility for treatment.

I understand that I will be contacted as soon as reasonably possible in the event an accident or emergency should occur, and I acknowledge that I am responsible for all reasonable charges in connection with any care and treatment rendered.

               

Please provide medical information relevant to your child to your Enrollment or Match Support specialist upon enrollment.

Confidentiality Policy

BBBSBC Confidentiality Policy


Big Brothers Big Sisters of Bucks County, Inc. respects the confidentiality of Youth and 

Volunteer records.  The records are not open for review by anyone including the Youth and 

Volunteer.  Exceptions will be made under the following situations: 


- Youth, parent/guardian, or volunteer signs a "Consent to Release" form. 


- An outside group such as Big Brothers Big Sisters of America and/or a designated 

member of the Board of Big Brothers Big Sisters of Bucks County obtains 

permission from the Chief Executive Officer or the Board of Directors for the 

purposes of program evaluation. 


- The agency is presented a subpoena by the courts. 


- Consultation is required with the agency's legal advisor. 


- There is a suspicion of child abuse, which requires the agency to make a report to 

the appropriate authorities. 

 

- A Youth or Volunteer threatens harm to himself or others, which requires the 

agency to take appropriate action. 

 

Agency professional staff will verbally disclose information about you to a potential match, and 

you will also receive information about a potential match partner.  The information you receive 

about a potential match partner is confidential, and it should not discussed with anyone other 

than your assigned case manager. 

 

I have read, understand, and received a copy of the above policy on confidentiality and agree 

to program participation under the conditions it sets forth. 

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

Child Safety Guidelines and Ground Rules for Volunteers


Maintain contact with Big Brothers Big Sisters of Bucks County (BBBSBC): 
- Maintain contact with BBBSBC on a monthly basis.  Promptly return any calls from the Match 
Support Specialist. 
- Stay in touch with your Match Support Specialist (monthly during the first year of the match and  quarterly thereafter) to advise them of your activities, the development of the match relationship between Big and Little, to receive coaching and feedback, and to relay any questions or concerns you may have. 
- Complete annual surveys conducted by your Match Support Specialist to provide BBBSBC 
feedback on your match relationship and child’s development. 
- Call BBBSBC at 215-343-8260 immediately with any child safety concerns/suspected abuse 
or to report an injury or accident. 
 
Roles and Boundaries: 

Parents/Guardians: 

- Parents/guardians should be aware and consent to all activities to which their child will 
participate. 
- Parents and/or guardians are ultimately responsible for the well being of their child.  Therefore, if the child has some conflict with school, law, etc., the Big should not intercede on behalf of the 
parent/guardian. 
- Parent will communicate with the Big to arrange times for the Little and Big to meet. 
- Regularly ask the Little questions about the match relationship, to ensure that the child feels safe comfortable, and happy.  (See Child Safety Guide for suggested questions.) 
- Parents should never ask a Big to do any favors not related to the match: babysitting, running 
errands, providing transportation not related to the match activity. 
- Keep personal information regarding your Big confidential and discuss only with BBBSBC. 

Bigs: 
- A Big’s relationship with a parent should be centered on the Little.  Bigs and parents should not 
get together on their own, and romantic relationships between Bigs and parents are prohibited. 
- Never come between the parent/guardian and child; respect parental role and authority. 
- When communicating any concerns about your Little, please do so privately with the 
parent/guardian and your Match Support Specialist. 
- Keep personal information regarding your Little confidential and discuss only with BBBSBC. 
 
Personal boundaries: 
- Affection is best expressed through positive /affirming comments. 
- Respect your Little’s personal space and privacy. 
- Physical affection may be expressed using a handshake, high five, pat on back or hug. 
- Wrestling, tickling, or children sitting on laps is prohibited. 
- Never sleep or nap with your Little in the same bed, sleeping bag, or sofa. 
- Contact your Match Support Specialist if there are any concerns about a Little’s boundaries or 
expression of affection. 
 
Involving family members/friends on match activities: 
- Remember, match relationships should be primarily one-to-one between Big and Little

Parents should not ask the volunteer to include any other children on match activities. Please: 
- Be aware that Bigs assume total responsibility and liability for any other person who attends a 
- Secure permission from Littles’ parent /guardian before inviting a friend or relative on a match 
- Others (ex:  significant others, friends, own children, Little’s siblings and friends) should only be 
included in match activities for special occasions and circumstances.
- Take into consideration the preference and comfort of your Little before including anyone 
- Be respectful of the volunteer’s time and commitment to your child. 

If inviting another minor child, Bigs must also get their parent’s permission before the 
activity takes place. Match activity who is not enrolled in BBBSBC and you are responsible for such third party’s behavior, supervision, and safety during the Match activity.

 
Supervision and transportation of child/youth: 
- Bigs are responsible for the supervision of your Little and at no time should the child be left 
unsupervised or left with someone else during a match activity. 
- Do not allow others to transport your Little (friends, family, roommate, partner). 
- Do not talk or text on a cell phone while transporting your Little in a vehicle. 
- Big must, maintain a working phone number where your Little’s parents or BBBSBC can 
contact you while on an outing with your Little and inform parent/guardian on where Big and 
Little plan to go. 
- Parent must, maintain a working phone number where your child’s Big can reach you, or 
provide a telephone number of a relative or neighbor, where you can be reached. 
- Big must create a plan with your Little that you will both follow if you get separated while on an 
outing. 
- Follow Pennsylvania state guidelines, which state that children ages 4-8, are required to be in a 
booster seat unless the child is over 80 lbs or at least 4’9” tall. It is also recommended that 
children under 13 ride in the back seat. Consult with a parent/guardian regarding their preference. 
- Drivers and passengers are required to wear a seatbelt wherever they sit in the vehicle. 

When returning child home after a match activity: 
- Ensure that your Little is safely in their home before leaving. 
- Don’t drop child off unattended unless previous arrangement has been made with the 
parent/guardian. 
- Check in with the parent/guardian letting them know how the activity went. 
 

If the child gets sick: 
- Parent/guardian must provide the Big and BBBSBC have the most up to date, relevant medical information;  including allergies, medical conditions, and insurance information in case of an accident. 
- Big may never give medication unless given written permission from the parent/guardian. 
- Big must always carry your Little’s current medical form and contact information and the 
BBBSBC phone number. 
- If Little or Big are sick on the day of a scheduled visit, please let each other know in advance and reschedule the activity for another day. 
 
 
General Safety: 

Matches are not permitted to have match activities in the Bigs home for the first three (3) months 
-Visits should not exceed once a week unless discussed with your Match Support Specialist. 
- Ensure that your Little wears a lifejacket when on a boat, dock and anywhere around the water. 
- BBBSBC insurance policy does not cover aircraft, motorcycle/all terrain vehicles, and firework 
- Escort the child to any public restroom to ensure safety. 
- Appropriate swimwear and changing facilities are required for swimming. 
- Provide separate/private areas for your Little to change or bathe. 
- Do not carry a firearm or have an unsecured firearm while in the presence of your Little. 
- Obtain Parent/Guardian permission before engaging in any activity dealing with a firearm or any 
- Children under 12 are required by law to wear an appropriate helmet while riding bike.  It is 
of their match. After their 3 month mark, activities at the Bigs home are up to the discretion of the Little and Parent/Guardian. 
strongly recommended that your Little wear a helmet while skateboarding, roller-skating, 
rollerblading, skiing, or snowboarding. 
potentially dangerous weapon. Discuss the proposed activity with your Match Support Specialist. 
accidents. 
 
Movies, video games, media, Internet: 
- Follow content ratings for all media forms (PG, PG-13, TV-14, M etc.) 
- Viewing content with your Little that contains explicit sex, graphic violence, or 
pornography is strictly prohibited, and grounds for match closure. 
- Obtain Parent/Guardian permission before connecting with your Little through social networking 
site. 
- BBBSBC strongly recommends Bigs, Littles and family members to not connect on social media. 
- Obtain Parent/Guardian permission before posting pictures of your Little on the Internet.
- Inform your Match Support Specialist of websites where you have posted pictures of your Little. 
 
Gift giving, donations, work for pay: 
- Small gifts are permissible for birthdays, holidays, special events, or recognition of personal 
achievement. 
- Gifts should never be purchased and kept at the volunteer’s home without the knowledge and 
permission of the parent/guardian and Match Support Specialist. 
- Large donations of furniture, clothing, money, computers, bikes or any professional services to 
Little/family are inappropriate and should be discussed with your Match Support Specialist. 
- Providing opportunities for your Little to earn money should be discussed with the 
parent/guardian and your Match Support Specialist. 
- The Big has no financial responsibility for the support of the child and/or the child’s family. 
 
Discipline/setting limits: 
- Physical discipline is never allowed. 
- State expectations for behavior, and set appropriate boundaries. 
- Verbally address behavior concerns, clarify what needs to change or happen. 
- If your Little does not respond, take him/her home and inform parent/guardian. 
- The Big is not a disciplinarian on behalf of the parent or guardian. The parent may not punish the child by refusing to let the child see his/her Big. However, we encourage the parent to enlist the support of the Big in addressing the child’s poor behavior. 
 
Use of alcohol, drugs, tobacco: 
- Do not consume alcohol or any illegal drug prior to or during a match activity. Do not 
engage in any illegal activity while in the presence of your Little. Do not purchase or use 
any tobacco products while in the presence of your Little. 

BBBSBC policy prohibits the use of any illegal drug and/or alcohol by either adult volunteers or 
boys/girls in the presence of one another. A violation of this policy will result in termination from 
the program. 
 
Personal stressors / life changes: 
- If at any time during your match you are experiencing significant life stressors which may 
interfere with your match, please discuss these circumstances with your Match Support Specialist. 
- Update your Match Support Specialist of changes in jobs, contact information, address, telephone 
number, connectivity, e-mail address, availability, etc. 
- Update Match Support Specialist of changes in Little’s family, significant other, living situation, 
health issues, safety issues, availability, inappropriate requests, etc. 
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