Youth Application Template

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. 
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 Big Brothers Big Sisters of the Southern Adirondacks 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 Big Brothers Big Sisters of the Southern Adirondacks, 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 Big Brothers Big Sisters of the Southern Adirondacks 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. 

 

Confidentiality Policy

Access to Confidential Records

 

In order for Big Brothers Big Sisters of the Southern Adirondacks to provide a responsible and professional service to clients, it is necessary for volunteers, clients and parents or guardians of clients to be asked to divulge extensive personal information about themselves and their families. The agency respects the confidentiality of clients and volunteer records, and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.  The right to confidentiality applies not only to written records, but also to video, film, pictures or use of any client or volunteer’s name in agency publications.

 

All records are considered the property of the agency and not the agency workers or clients or volunteers themselves.  In order to provide a service, which is in the best interest of the children served by the program, information from outside sources, including confidential references, must be assessed along with the information gained from the clients or volunteers themselves.  Records are not available for review by the clients or volunteers.  Clients and volunteers shall be provided, at the time of application, a copy of this statement on confidentiality along with the exceptions that define the limits of confidentiality.  Clients and volunteers shall sign a statement that he/she has to read and understand the agency policy on confidentiality and agree to program participation under the guidelines it sets forth.

 

 

Limits of Confidentiality

 

1.  Information will be released to other individuals or organizations only upon presentation of an authorized “Consent to Release Information” form appropriately signed by the client or volunteer.

 

2.  Identifying information regarding clients and volunteers may be used in agency publications or promotional materials if the client or volunteer has given permission.

 

3.  For purposes of program evaluation, audit or accreditation, and with the prior approval of the Board of Directors, certain outside bodies such as the Big Brothers Big Sisters of America may have access to client and volunteer records.  These outside organizations shall be required to use the information only for the purpose(s) stated in the approval action of the Board of Directors.  Known violations of agency confidentiality policy will be reported to the supervisor of the individual involved and appropriate disciplinary action shall be requested.

 

4.  Members of the Board of Directors have access to client files only upon authorization by formal motion of the Board of Directors.  The motion shall state who shall be authorized to review records, the specific purpose for such a review, and the period of time during which access shall be granted.  The member shall be required to comply with the agency policies on confidentiality and may use the information only for purposes stated by the approval action of the Board of Directors.  Known violations shall be reported to the Board President.  A violation of the agency’s confidentiality policy by a Board Member shall constitute adequate cause for removal from office.

 

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

 

6.  Information shall be provided to an agency legal counsel in the event of litigation or potential litigation involving the agency.  Such information is considered privileged information and law protects its confidentiality.

 

7.  State law mandates that suspected child abuse be reported to the appropriate authorities (designated state agency).  All workers are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.

 

8.  If any 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 person.  This may include a medical referral or a report to local law enforcement authorities.

 

I have read and understand the above document which states the agency policy with respect to confidentiality of client and volunteer records.  I agree to program participation under the conditions it sets forth.

 

I agree to keep information discussed with me regarding a potential (Big Brother/Sister, Little Brother/Sister) match confidential.  I will not discuss this information with any person other than the assigned professional staff of the Big Brother Big Sister agency.

 

 

 

Regional Office: 1 Lawrence Street, Suite 1B, Glens Falls, NY 12801

 (5I8) 798-1010 (fax) 798-1517

 

Contact Information