BY SIGNING BELOW I GIVE PERMISSION:
1. For my ongoing participation in the Big Brothers Big Sisters of Island County Programs, which include both the DINO program and the one-to-one mentoring programs;
2. For the mentors, as well as staff and the identified designees who have been screened and approved by Big Brothers Big Sisters to personally interact with and transport me to events, activities and match activities, if applicable and allowed by program type;
3. For the school to provide social and academic information about me to Big Brothers Big Sisters (e.g. report cards, behavior reports);
4. To have me participate in an intake interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout my time in the program containing questions about school, home life, the match, and personal interests to evaluate and improve program services;
5. To talk with a Big Brothers Big Sisters staff person about personal safety;
6. For BBBS staff to provide contact information for me to DINO program coodinators when appropriate.
I understand 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 me will be discussed with DINO program coordinators (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, completely release and forever discharge Big Brothers Big Sisters of Island County 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 Island County, 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 me directly. 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.
I agree to review the program and safety information given to me by Big Brothers Big Sisters, communicate with Big Brothers Big Sisters staff as outlined in expectations, and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.