Youth Application

Non-Discrimination Policy

It is the policy of Big Brothers Big Sisters of Salina to provide equal opportunity for program participation to Bigs/volunteers, children and families without regard to the individual race, color, religion, national origin, marital status, age, gender, gender identity, sexual orientation, veteran’s status, status with regard to public assistance, or disability of qualified individuals.

Hidden Fields

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Youth Information

First Name

Last Name

Middle Name

Preferred Name/Nickname

Birthdate

Enter a date in the following format: mm/dd/yyyy

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?

Race/Ethnicity

Nationality/Country of Origin:

Hold CTRL+F to select multiple

Tribal & Regional Corporation Affiliations

School

Grade

School Account ID

Youth's Email

Youth's Phone

What program would you like to enroll your child in:

Community Based Program - Little spends time with Big in the community. Site Based Program - Child spends time with Big at a designated school/location. Not seeing Big outside of this location.Interested in enrolling my child in any BBBS program.

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Preferred Name/Nickname

Mobile Phone

Home Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Contact Preference

PhoneEmailText/SMS

Employer

Type NA if unemployed

Guardian's Relationship to Youth

Do you have legal custody of this youth?

YesNo

Is there a person who shares custody of this youth?

YesNo

Name

Phone

Are they aware and supportive of the youth's enrollment in the BBBS program?

YesNo

Family Information

Youth Living Situation

Living Situation Description

Who else currently lives in the home (i.e. other adults, family members, siblings(s), roommate(s), etc.)?

Languages Spoken in the Home:

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Please check here if your mailing address is different from your residential address:

Residential Address

Street Address

City

State

Zip Code

Emergency Contact

If we are unable to reach you, who is someone we could call who always knows how to reach you?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Parent/Guardian Agreement

By checking the box below and providing my signature at the end of this form, I give permission:

For my child to participate in the Big Brothers Big Sisters Program;
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;
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;
To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
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, on behalf of myself and my child, completely release and forever discharge Big Brothers Big Sisters of Salina 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 Salina, 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.

I accept the terms and conditions

Parent/Guardian Electronic Signature:

This will used as your signature for the document above.

Today's Date:

MM/DD/YYYY

School	Relative
Faith Organization	Counselor/Therapist
Service Organization	Someone currently/formally involved in the program
Website	TV/Radio
Event	Other (please provide details below)

Special education	Speech therapy
Tutoring	In-school counseling
Other counseling	None

Youth Application

Additional Questions

Parent/Guardian Agreement