Youth Application BBBS-SWI

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Non-Discrimination Policy
Applicants will not be denied services based on race, color, creed, religion, national origin, gender, gender identity, marital status, sexual orientation, veteran status, disability, income, housing status, or citizenship. 
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 NO EMPLOYER



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





Family Relationships






Youth Health Questions









Demographic Information
The next set of questions are to better understand you, your family and your youth. NO YOUTH WILL BE DENIED SERVICES BASED ON THESE ANSWERS.

























Personality and Interests






School







Match Preferences

We will try to match your youth based on your stated preferences. Please note, BBBS-SWI does not discriminate based on age, gender, gender identity, sexual orientation, race, religion, or national origin. We are unable to guarantee a match .


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 school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);
  3. 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;
  4. To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
I understand that: 
BBBS-SWI is not obligated to match my child with a volunteer.

My child and I will be interviewed, in person, as part of the enrollment process.

The information I provide in the enrollment process will be kept confidential, unless disclosure is required by law. 

Incidents of child abuse or neglect, past or present, will be reported to proper authorities.

Certain relevant information about my child will be discussed with the volunteer who is a prospective match I certify that all of the information on this form is true and correct. 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.

COPPA Parental Consent Form

Notice to Parents In compliance with the Children’s Online Privacy Protection Act (COPPA), parents/guardians of children under 13 years of age must consent to collections, uses, and disclosures of the personal information of their children collected by BBBS-SWI on BBBS-SWI and BBBSA websites and online software necessary for agency operations.  BBBS-SWI may have collected contact information from you, your child or a 3rd party such as teacher, counselor or grandparent.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.
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