Sports Buddies: Child Enrollment Form

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Mentor Program

Which of the following Site-Based facilitated programs are you applying for?

Program ID - OC

Child Information

Note: this information will be used ONLY to help choose the most beneficial match for your child. This information will NOT be considered in determining whether or not your child is accepted into the program.

Child's First Name

Child's Middle Name

Child's Last Name

Child's Date of Birth

Please include the slashes above.

Gender

How does the child identify?

Race/Ethnicity

School

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School Account ID

School District

Current Grade Level

Student ID

High School Graduation Year

This is the year the child will graduate high school.

Is the child eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

Does the child have a parent/guardian who is currently incarcerated?

YesNo

Annual Household Income

Number of people supported by this income:

Household Living Situation

Living Situation Description

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Mailing Street Address

Please include unit or apartment #

Mailing City

Mailing State

Mailing Zip Code

Date of Birth

Please include the slashes above.

Age

What is your primary language?

Start typing to search

Mobile Phone

Can we send texts to the mobile phone number provided above?

Yes, I agree to receive updates, reminders, and event opportunities text messages from Big Brothers Big Sisters. Agreeing to this isn't a condition of participation in the program. I agree to the Terms of Service and Privacy Policy. Approx. 4 Msgs/Month. Msg & data rates may apply.

Home Phone

Work Phone

Work Phone Extension

Preferred Phone

Best Time to Call

May we contact you at work?

YesNo

Does the child have their own phone?

YesNo

Child's Phone

Parent/Guardian's Relationship to Child

Parent/Guardian's Email

Child's Personal Email

Child's School Email

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Street Address

Emergency Contact City

Emergency Contact State

Emergency Contact Zip Code

Emergency Contact Phone

Emergency Contact Relationship to Child

Additional Child Information

How often does your child enjoy playing sports and participating in other physical activities on a weekly basis?

Please give the days and times of any after-school activities your child participates in throughout the year:

Will your child have reliable transportation to and from the Sports Buddies Program Match events 1-2 times a month?

YesNo

Pertinent Medical History

Please mark boxes to indicate if your child has any of the following health conditions:

AsthmaAllergiesDiabetesSeizuresOther

Allergies Description

(ex. Peanuts, bees, penicillin)

Do you have Health/Medical Insurance?

YesNo

Is your child taking any medications?

YesNo

Medications Description

(ex. EpiPen, Inhaler)

Does your child have any mental health concerns (currently in therapy, emotional or behavioral plan at school, ADHD, etc.)?

Describe your child's environment and family structure?

Has the child ever been involved with the police or juvenile justice system?

YesNo

What kind of custody do you have of your child?

Explain

Do you have any preferences regarding the volunteer who may be matched with your child as a Big Brother or Big Sister?

Note: Your child will be matched with a volunteer of the same gender.

How did you hear about Big Brothers Big Sisters?

Referral Detail ID - OC

Child Needs Assessment

My child needs assistance in the following areas:

School PerformanceFriendship & Peer RelationshipsSelf-Esteem & ConfidenceClassroom BehaviorBeing ActiveOtherCheck all that apply

Please explain:

My child excels in the following areas:

School PerformanceFriendship & Peer RelationshipsSelf-Esteem & ConfidenceClassroom BehaviorBeing ActiveOtherCheck all that apply

Please explain:

In what others areas have you noticed your child needs guidance?

Acting with ConfidenceAnger ManagementBuilding RelationshipsCommunicationDecision MakingExpressing Themselves AppropriatelyFinancial PlanningMeeting new peopleOrganizationParticipating in Group ActivitiesRespecting AuthorityRespecting BoundariesShowing Consideration to OthersSocial SkillsStaying FocusedStaying MotivatedThinking about Long Term Effects of ChoicesThinking IndependentlyTime ManagementTrying New Things

Terms and Condtions

Program Description: One-on-one mentoring supervised and held at various Orange County Locations. The Sports Buddies program has a one year commitment with two sessions being offered each month beginning in September.

1. I, the parent/guardian of

, hereby give my permission for him/her to participate in the Big Brothers Big Sisters of Orange County/Inland Empire ("BBBSOC/IE") Sports Buddies Program (the "Program") in various Orange County locations

2. I understand that my child will be matched one-to-one with a volunteer Big Brothers Big Sisters mentor. The match events will be offered two Saturdays a month in Orange County, my child is expected to attend at least one match event a month with their mentor.

3. I understand that for my child to participate in this program, he/she will be interviewed and photographed by BBBSOC/IE; this is for identification purposes only, subject to the Media Consent Agreement below.

4. I understand that all information received will be kept confidential, within the agency's limits of the law, except for purposes associated with the Program. California law requires that all professionals who work with families and children under the age of 18 report suspected and known incidents of child abuse, as well as threats of harm to self or others.

5. I, the undersigned, understand that all information my child or I disclose to BBBS, whether disclosed in the Child Enrollment Form, questionnaires, interviews or otherwise, and whether in writing or orally, may be disclosed to the prospective or matched Big Brother/Big Sister and I hereby consent to such disclosure.

6. I understand that all information obtained through the application process is the sole propery of BBBSOC/IE.

7. I understand that my child and I will be contacted via telephone or mail by BBBSOC/IE

staff to discuss my child’s participation in the program.

8. I understand that BBBSOC/IE requires access to my child’s school records for the purpose of program evaluation. I hereby permit BBBSOC/IE to access my child’s grades, attendance and other school records as necessary.
9. I agree to provide reliable transportation to and from Sports Buddies match events:

I Agree

10. I have read and understand the above statements and agree for my child to participate in the Sports Buddies mentoring program.

I Agree

Parent/Guardian Signature
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Printed Name of Parent/Guardian

Date Signed

Media Consent and Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”). I hereby accept the invitation of Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) for My Child to appear and be identified in print or online in any BBBSOC/IE publication or production. I hereby grant BBBBSOC/IE and its affiliates the absolute right and permission to use the image, name, and biographical information of My Child as BBBBSOC/IE may desire, in all media and in all forms whatsoever, including, but not limited to: magazines, brochures, press releases, print publications; motion pictures, television, cablecast and satellite broadcasts; the internet and mobile applications. Examples include, but are not limited to, the Orange County Register and other print news media, televised news media, promotional print media, and the BBBSOC/IE website and social media channels. In consideration of $0 to be paid to me, I hereby grant to BBBSOC/IE and its affiliates the absolute right to use images made through BBBSOC/IE studios or elsewhere, in whole or in part, in true or distorted character or form, alone or in conjunction with any other image, name or reproduction, in color or otherwise, for art, advertising, promotion, business, trade, or any other lawful purpose whatsoever, in perpetuum. I hereby waive any right that I may have to inspect and/or approve of the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied.

I hereby release BBBSOC/IE and its affiliates from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSOC/IE ’s exercise of the right hereby granted. These include, without limitation, claims for compensation, claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory. BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Initials

2. I do not grant Big Brothers Big Sisters of Orange County/Inland Empire the right to use the image of the minor child specified below.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
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Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relationship to Participant

Program Behavioral Policy

It is important that staff maintain order and discipline in all programs. Top objectives in all BBBSOC/IE programs are safety and a positive atmosphere for learning and developing skills. The staff makes every effort to help children understand clear definitions of acceptable and unacceptable behavior. A child’s behavior is expected to be consistent with the following: Use appropriate language at all times, cooperate with staff and follow directions, respect other children and staff, equipment, facilities and yourself, maintain a positive attitude, keep hands, feet and other objects to self and stay in program areas. Behaviors Resulting in Immediate Program Dismissal but are not limited to: ● Any action that could threaten or pose a direct threat to the physical/emotional safety of the child, other children or staff. ● Fighting or bullying ● Possession of a weapon of any kind ● Vandalism or destruction of school property, program property or property of others. ● Running Away ● Biting Parents/guardians are required to inform BBBSOC/IE in writing prior to a child’s acceptance in the program of any special circumstances which may affect the child’s ability to participate fully and within the guidelines of acceptable behavior, including, but not limited to any serious behavioral problems or special circumstances regarding psychological, medical or physical conditions.

Accidents/Illness/Emergency: When a child becomes ill or is injured during the program, the parent/guardian will be contacted immediately. If the parent cannot be reached our staff will adhere to the emergency contact information on your child's registration form. Please notify us immediately if changes occur in addresses, phone numbers or emergency contacts for your family. Should we not be able to reach anyone, we will call 911 for transport to needed medical facilities. I have read and understand the above statements and agree for my child to participate in the High School Bigs mentoring program.

I Agree

Parent/Guardian Signature
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Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relationship to Participant

Athletic Waiver and Release Form

The Big Brothers Big Sisters of Orange County and the Inland Empire applicant information and release form must be signed with no additions, deletions, or changes for the participant to take part in Sports Buddies activities. We want to make sure you understand the risks associated with participation in varying strenuous activities and have carefully considered whether you want to participate.

RELEASE FORM: The program that you have signed up for involves physically and emotionally demanding activities. It includes climbing, jumping and other rigorous activities in low, medium or high distance from the ground. It is possible that you may be injured while participating in the program either because of your own conduct, conduct of others in the group, conduct of the Sports Buddies program, or the conditions of the premises. We want to make sure that you understand the risks of injury before you decide to participate in the program. It is required that you read the following very carefully, make sure you understand it and sign it before you begin participating in the program.

I AM FULLY AWARE THAT I AM CHOOSING TO PARTICIPATE IN RIGOROUS PHYSICAL ACTIVITIES. I AM ALSO AWARE THAT THERE ARE RISKS OF PHYSICAL INJURIES OR HARM FROM PARTICIPATING IN THE SPORTS BUDDIES PROGRAM. I VOLUNTARILY ELECT TO PARTICIPATE IN THE PROGRAM AND TO ASSUME THE RISKS OF INJURIES OR HARM THAT INCLUDE RESULTS FROM PARTICIPATION. ON MY OWN BEHALF, AND ON BEHALF OF MY PERSONAL REPRESENTATIVES AND HEIRS, I HEREBY RELEASE THE BIG BROTHERS BIG SISTERS OF ORANGE COUNTY AND THE INLAND EMPIRE, INCLUDING ITS OFFICERS, EMPLOYEES, CONSULTANTS, AGENTS, AND DIRECTORS FROM ALL LIABILITY FOR ANY INJURIES OR HARM TO ME FROM PARTICIPATING IN SPORTS BUDDIES PROGRAM ACTIVITIES, WHETHER THE INJURY OR HARM IS CAUSED BY THE NEGLIGENCE OF THE SPORTS BUDDIES PROGRAM, OR OTHERWISE. I HAVE READ AND UNDERSTAND THIS RELEASE OF LIABILITY. I VOLUNTARILY SIGN IT AND I HEREBY GIVE PERMISSION ADMINISTER BASIC FIRST AID OR TO SEEK APPROPRIATE MEDICAL ASSISTANCE FOR THE PARTICIPANT LISTED ABOVE

Parent/Guardian Signature
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Participant Signature
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Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relationship to Participant

Communication Consent & Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”), who is participating in the Adult Site Based Program (the “Program”) offered by Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) as a volunteer mentee, or “Little”. I hereby consent and give My Child permission to communicate virtually and/or electronically with My Child’s Big or mentor, and other Littles or mentees participating in the Program. Such communication may include, without limitation, telephone, text message, email, and video conferencing programs such as Zoom, CommandLink, Google Classroom, and FaceTime. Such communication may also include social media platforms including, without limitation, Instagram, Facebook, Twitter, and TikTok, and online video game platforms including, without limitation, Xbox Live, Nintendo Switch Online, and PlayStation Plus.

I WILL COMMUNICATE WITH MY CHILD, WITH MY CHILD’S BIG OR MENTOR, AND WITH BBBSOC/IE TO DETERMINE WHICH COMMUNICATION METHODS AND PLATFORMS I APPROVE.

I further agree to supervise, monitor, and otherwise stay informed about My Child’s virtual and/or electronic communication with My Child’s Big or mentor, and to maintain an open dialogue with My Child concerning these virtual and electronic interactions.

I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, volunteers, agents, affiliates, successors, and assigns, arising out of or attributable to My Child’s virtual and/or electronic communication with My Child’s Big or mentor, and other Littles or mentees participating in the Program.

BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Initials

2. I do not consent or give My Child permission to communicate virtually and/or electronically with My Child’s Big or mentor, or other Littles or mentees participating in the program.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
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Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relationship to Participant

RELEASE AND WAIVER OF LIABILITY

I, the undersigned, am the parent and/or legal guardian of

a minor (“My Child”), and I agree to permit him/her to attend and participate in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) Sports Buddies Program (the “Program”).

I understand that certain risks and dangers may exist in My Child’s attendance and participation in the Program, and such attendance and participation is conditioned upon my agreement to release BBBSOC/IE from any claims of liability, including, but not limited to, any claims for property loss or personal injury to My Child. Therefore, in exchange for the opportunity of My Child to attend and participate in the Program, I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, agents, affiliates, successors, and assigns (collectively, “Releasees”), on account of injury, death, property damage, or economic loss arising out of or attributable to My Child’s participation in the Program, including, without limitation, to travel to or from their school/site or field trip/program destinations, whether arising out of the ordinary negligence of BBBSOC/IE or any Releasees or otherwise. I covenant not to make or bring any such claim against BBBSOC/IE or any other Releasee, and forever release and discharge BBBSOC/IE and all other Releasees from liability under such claims. This waiver and release does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that California law does not permit to be released by agreement.

I understand that by signing this agreement, I am waiving for My Child any and all claims, of any kind arising out of or attributable to My Child’s participation in the Program, including those claims that may be unknown to me, or which I do not suspect to exist at this time. WITH THE INTENTION OF WAIVING ALL UNKNOWN AND UNSUSPECTED CLAIMS, I HEREBY EXPRESSLY WAIVE ALL RIGHTS, BENEFITS, AND PROTECTIONS I MAY HAVE UNDER CALIFORNIA CIVIL CODE SECTION 1542, WHICH READS AS FOLLOWS:

“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.”

I shall defend, indemnify, and hold harmless BBBSOC/IE and all other Releasees against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys’ fees, fees and the costs of enforcing any right to indemnification under this agreement, and the cost of pursuing any insurance providers arising out of or resulting from any claim of a third party related to My Child’s participation in the Program, including any claims arising out of my own negligence, the negligence of My Child, or the ordinary negligence of BBBSOC/IE.

THIS AGREEMENT PROVIDES BBBSOC/IE WITH MY ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE BBBSOC/IE FOR ANY CLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM.

I Agree

Parent/Guardian Signature
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Printed Name of Parent/Guardian

Date Signed

Printed Name of Minor Participant

Relation to Minor Participant

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