Safford Little 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.

Preliminary Questions

Who is filling out this form?

Please write the Matchforce Owner this should go under

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

Parent/Guardian Birthdate

Enter a date in the following format: mm/dd/yyyy

Parent/Guardian Gender/Gender Identity

How do you identify?

Parent/Guardian Personal Pronouns

What pronouns do you use?

Mobile Phone

Home Phone

Personal Email

Employer

Type NA if unemployed

Job Title

Parent/Guardian Relationship Status

Guardian's Relationship to Youth

Number of Household Members

Emergency Contact

If we are unable to reach you, who is someone we could call who always knows how to reach you?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Consent Forms

Consent for Evaluation Surveys

I give my consent for myself and my child to participate in all assessment and evaluation services, to cooperate and assist in all planning activities and to receive all services for my child as deemed necessary by BBBSSA.

I consent to my child completing a questionnaire containing questions about school, home life, and personal interests.

Permission/Pictures of Your Child

BBBSSA will have various opportunities throughout the year to showcase pictures, videos and additional items of your child's match. These items are used in many promotional materials, and help our recruiting efforts as well. No personal or confidential information will be shared when sharing these forms of media. Please read through the following statements below, so that we may include your child in our media once matched.

I consent for all purpose to the reproduction and/or use of photographs of my child (with or without the use of his/her name) by Big Brothers Big Sisters of Southern Arizona and by any nominee or designee of Big Brothers Big Sisters (including any agency, client, periodical or other publication) in all forms and media and in all

manners, including social media, advertising, trade, display, editorial, art, and exhibition. In giving this consent, I release Big Brothers Big Sisters, their nominees and designees from liability for any violation of any personal or proprietary right I may have in connection with such reproduction, or use. I am the parent/guardian of the minor named above and have the legal authority to execute the above consent and release. I approve the forgoing and waive any rights in the premises

You have reached the end of the application. We will need an "e-signature" to complete the application.

Parent/Guardian E-Signature

Full Parent/Guardian Name

I have read and understand the above statements. As the parent/legal guardian of the above named student, I give my permission for him/her to participate in the BBBSSA High School Mentor Program. To plan for the academic needs of my child, I give permission for BBBSSA staff to obtain any pertinent information regarding

their school status from their teacher.

Signature - Typing my name below serves as my signature.

Staff

I, the staff member, have filled out this child application according to what the parent/guardian or other reliable source has provided me via printed handout or interview detail. I agree that I only copied what the Parent/Guardian has provided.

Staff Member Name

American Indian or Alaska Native	Asian - Chinese
Asian - Filipino	Asian - Indian
Asian - Japanese	Asian - Korean
Asian - Other	Asian - Vietnamese
Black or African American	Hispanic - Cuban
Hispanic - Mexican,Mexican American,Chicano	Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican	Middle Eastern or North African
Pacific Islander - Chamorro	Pacific Islander - Native Hawaiian
Pacific Islander - Other	Pacific Islander - Samoan
White or Caucasian	Other
Prefer not to say

English	Spanish
African Languages (Swahili, Bantu)	American Sign Language
Arabic	Asian: Other
Chinese	Creole
Dutch	Eastern European (Czech, Slovak)
French	German
Greek	Hebrew
Hmong	Indian (Hindi, Punjabi)
Italian	Japanese
Keres (West)	Korean
Nordic	Persian
Portuguese	Russian
Turkish	Lao

CPS	Therapy
Tutoring	In-school counseling
Other counseling	None