Community Youth Application for BBBS of Southwestern Indiana

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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. 
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 grade the youth is currently in. (If it's the summer, then it will be the grade they are going into)






Guardian Information













Parent/Guardian Employment

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?
Agency Questions





Other Siblings and Relatives in the Program
Please choose this youth's relationship to the following people:
Family Relationships






Health









Demographic Information
The following information is for demographic and tracking purposes only. No youth shall be excluded from the program on the basis of the following information. 

























Personality and Interests






School







Match Preferences

We will make every effort to honor your preferences for your youth's mentor. BBBS does not discriminate on the basis of race, ethnicity, gender, gender presentation, marital status, sexual orientation, or religion.


Match Qualifiers
Do you have any concerns or preferences regarding a volunteer who:











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.
  7. For my child's counselor, therapist or court appointed special advocate (CASA) to provide behavior, emotional, academic or demographic information about my child to BBBS enrollment staff, for the purpose of determining my child's eligibility. 
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 Southwestern Indiana 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 Southwestern Indiana, 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 Southwestern Indiana 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. 

 

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 Big Brothers Big Sisters of Southwestern Indiana on Big Brothers Big Sisters of Southwestern Indiana and NATIONAL websites, including mentoringkids.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of Southwestern Indiana COPPA statement is incorporated in the website Privacy Policy here: [POLICY] Big Brothers Big Sisters of Southwestern Indiana 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 give us permission. BBBS website accounts provide access to BBBS content, materials, and resources relating to BBBS programs and activities, including information pertaining to [MATCHES ETC.] 

You may revoke your consent to refuse further collection and use of your child’s information. If you desire to revoke this consent, please contact our agency at (812) 425-6076.

Program Confidentiality Policy

TO BE READ AND SIGNED BY AGENCY GUARDIANS AND VOLUNTEERS


Big Brothers Big Sisters of Southwestern Indiana (the Agency) respects the confidentiality of guardian, child, and volunteer records and, with the exception of situations listed below, shares information about guardians, children, and volunteers only among the Agency's professional staff. All records are considered the property of the Agency and not the Agency staff or children, guardians, or volunteers themselves. Records are not available for review by guardians, children, or volunteers.


Information will be released to other individuals or non-BBBS organizations only with the guardian or volunteer’s written consent.


Identifying information regarding children, guardians, and volunteers may be used in agency publications or promotional materials unless the guardian, child, or volunteer requests otherwise.


For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies such as Big Brothers Big Sisters of America may have access to child, guardian, and volunteer records.


Members of the Board of Directors or evaluators appointed by the Board have access to child, guardian, and volunteer files upon authorization of the Board of Directors.


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


Information shall be provided to the Agency’s legal counsel in the event of litigation or potential litigation involving the Agency.


State law mandates that suspected child abuse be reported to the appropriate authorities, law enforcement, or Child Protection Services.


CHILD ABUSE HOTLINE FOR INDIANA is 1-800-800-5556.


CHILD ABUSE HOTLINE FOR KENTUCKY, CALL 1-800-752-6200.


The NATIONAL CHILD ABUSE HOTLINE is 1-800-422-4453.


If Agency Staff receives information indicating that a child, guardian, or volunteer may be dangerous to themselves or to others, necessary steps shall be taken to protect the appropriate party. This may include a medical referral or a report to the local law enforcement authorities.


At the time a child or volunteer is considered a match candidate, information is shared between the prospective match parties. The information about the volunteer may include such items as age, sex, race, religion, interests, hobbies, marital status, family status, sexual orientation, living situation, etc. Information about the child may include such items as age, sex, race, religion, interests, hobbies, family situation, etc.

 

The Agency does not discriminate on the basis of these factors: race, religion, or sexual orientation of the volunteer, guardian, or child. Volunteers with various characteristics may be accepted. The volunteer has the right to accept or reject a potential child as their Little. The guardian and child have the right to accept or reject a potential volunteer as their Big.

COMMUNITY BASED GROUND RULES FOR LITTLES

 

The Big and Little relationship is a one-to-one friendship. The Big is the only one allowed to drive the Little, or spend one-on-one time with the Little.


The Big is responsible for keeping the Little safe when they are together. If a Little doesn’t feel safe, they should tell another special adult.


The Big and Little must always get approval from the Little’s guardian before an outing, activity, or time spent together. 


The Big is responsible for showing up on time for outings and for returning the Little home by the time. The Little is responsible for being ready and prepared on time. 


The Big is responsible for obeying all speed limits and traffic laws while transporting the Little. 


The Little and Big are not allowed to have overnight visits. These rules must be followed, or the match will be closed. 


Alcohol or illegal drug use is never allowed before or during match visits, outings, and activities.


The Little should never ask the Big for money or to buy something for them or their family.


The Big never takes the place of the guardian. The guardian is responsible for handling problems that may happen, such as at school, at home, or with the police. The Little should talk to the Big as a friend about these problems.


The guardian should know about all outings. The Little should talk with the guardian about these outings, including what they did, who was there, and how the Little feels about the outings. 


The Little is responsible for telling their guardian of any concerns, areas of discomfort, fears, dislikes, or confusion occurring between them and the Big. The Little is to talk to their Case Manager when they visit them at school, at home, or call to complete Match Support. They are to ask questions and share concerns, discuss outings, and how they feel about their Big.  Case Managers will be there to answer questions, hear comments and concerns, serve as a resource, and help when needed.

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