Enroll A Child - Application

Youth Basic Information


Please enter full middle name. Not initials.


*If youth does not have any other names, please enter N/A

Youth must be at least 6 years old at time of application.






Use CTRL click to multi-select all that apply.

Youth Emergency Contact Information




School





Health and Well-Being




What activities is your child interested in?

Home Life





Additional Information







Program Interest






Legal Guardian Information



Please enter full middle name. Not initials.























Participation Agreement
As the legal guardian of my child, I give full permission for the following:

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, has permission to transport my child to events and match activities.(Community-Based match only) 

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 in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout their time in the program containing questions about school, home life, and personal interests.

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

6. BBBS staff may provide contact information for me and my child to the volunteer. (Community-Based match only)

7. For Big Brothers Big Sisters staff to meet with my child at their school and/or afterschool program center to conduct an interview and/or match support.

8. For my child’s Big to meet with them at their school.

 

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 complete needed surveys to track my child's progress in the program. If my child is enrolling into the Community-Based mentoring program, I will be asked 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 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 (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 child's qualification for the 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 guardian. 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, 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.

Confidentiality Agreement

1. All information that I may encounter about any child, child’s family, volunteer Big, the volunteer Big's family or anything else of a confidential nature about any child or volunteer in any way connected with Big Brothers Big Sisters WILL BE HELD CONFIDENTIAL.

2. Any information that reveals or tends to reveal the identity of any person who is the subject of the record WILL BE HELD CONFIDENTIAL.

3. The identity of any person who contributes information to the subject record WILL BE HELD CONFIDENTIAL.

4. The results of any inquiry into school records or medical records of any description WILL BE HELD CONFIDENTIAL.

5. I will NOT discuss any information that I am privileged to receive with any other person without the verbal or written permission of the program staff.

6. I will only release prior approved information to the individual to whom I have been given permission to release the information.

7. I agree to hold all related information confidential and, except as I may be legally required, I will NOT disclose or release it to any individual or corporation at anytime.

8. I understand that Big Brothers Big Sisters agrees to hold all related information confidential and, except as we may be legally required, we will NOT disclose or release it to any individual or corporation at anytime.


Media Release

Social Media Release

Consent for Surveys and Training

REVIEW APPLICATION BEFORE SUBMISSION
Please review the information in the application BEFORE clicking Submit. When you click Submit and you are directed to a "Thank You" message, your child's application was received.

Please DO NOT click the back arrow and resubmit the application. 

If you need additional assistance, please email Katie at katie@becomeabig.com

Thank you!