Site- & School-Based Youth/Family Application

Welcome to Big Brothers Big Sisters of Connecticut!
Thank you for deciding to submit your application to enroll your child with Big Brothers Big Sisters of Connecticut! We are thrilled to have you join our community. By enrolling your child as a Little with our agency, you're connecting them both with a transformative program and mentorship experience that has the opportunity to help shape their lives for the better. By entrusting us with this partnership, you're joining a family that deeply values growth, understanding, and nurturing long-lasting relationships. We're excited and grateful for the opportunity to partner with you to help pave the way for a brighter future for your child. This application should take approximately 15 minutes to complete. You may stop and save your progress to return to the application if you would like to.
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. 
Notice on the Use of Artificial Intelligence
Agency staff may use approved Artificial Intelligence tools to assist in preparing program materials, generating anonymized reports, and improving service efficiency. AI is never used to make decisions about program eligibility, match suitability, or program participation, and we do not input any personally identifiable information (PII) into AI systems. All AI-generated content is reviewed by staff to ensure accuracy, safety, and alignment with our mission and values.
Filling Out this Application
If you need help or clarification when filling out this application, please contact your Program Specialist. If at any point you have technical difficulties, please contact shasityr@ctbigs.org. You may also call the office at 860-525-5437, option 2.
Hidden Fields
To look up the owner's email for notifications
For notifications
Youth Information
mm/dd/yyyy

Hold CTRL+F to select multiple

This is the year the youth will graduate.
Additional Information About the Youth









Please choose this child's relationship to the following people:







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

Parent/Guardian/Caregiver Information
Type NA if unemployed
Family Information
Please Note: The information requested below is kept strictly confidential and used only for program improvement and grant reporting purposes.

Residential Address







Emergency Contact
If we are unable to reach you, who is someone we could call who always knows how to reach you?
Transportation and Pick-Up


Afterschool Program Questions



Authorized Adult

Program Agreements and Authorizations

To enroll your child in our mentorship programs at Big Brothers Big Sisters of Connecticut, parents, guardians, and caregivers must understand and agree to the following terms. Please read each policy attentively and indicate your agreement by checking the boxes provided.
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.
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 Connecticut 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 Connecticut, 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.

ACCESS TO CONFIDENTIAL RECORDS


In order for Big Brothers Big Sisters of Connecticut to provide a responsible and professional service to clients, it is necessary for volunteers, clients and parents or guardians of clients to be asked to divulge extensive personal information about themselves and their families.  The agency respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about the clients and volunteers only among the appropriate agency staff.  The right to confidentiality applies not only to written records and conversations, but also to video, film, pictures or use of clients or volunteer’s name in agency publications.


All records are considered the property of the agency and not that agency workers or clients or volunteers themselves.  In order to provide a service which is in the best interest of the children served by the program, information from outside sources, including confidential references must be assessed along with information gained from the client or volunteers themselves.  Records are not available for review by the clients or volunteers.  Clients and volunteers shall be provided at the time of application and staff at the time of hire, with a copy of this statement on confidentiality along with the exceptions, which define the limits of the confidentiality.  Staff, clients and volunteers shall sign a statement that he/she has read and understands the agency policy on confidentiality and agrees to follow the guidelines it sets forth.


LIMITS OF CONFIDENTIALITY

  1. Information will be released to other individuals or organization only upon presentation of an authorized “Consent to release information” form appropriately signed by the client or volunteer.
  2. Identifying information regarding clients and volunteers may be used in agency publications or promotional material if the client or volunteer has given permission.
  3. 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 client and volunteer records.  These outside organizations shall be required to respect the agency policy on confidentiality.  Outside parties shall be required to use information only for the purpose(s) stated in the approval action of the Board of Directors.  Known violators and appropriate disciplinary action shall be requested.
  4. A violation of the agency’s confidentiality policy by a staff member will be subject to disciplinary actions up to and including dismissal.
  5.  Members of the Board of Directors have access to client files only upon the authorization by formal motion of the Board of Directors.  The motion shall state who shall be authorized to review records, the specific purpose for such review and the period of time during which access shall be granted.  Members shall be required to comply with the agency policies on confidentiality and may use the information only for the purpose stated by the approved action of the Board of Directors.  Known violations shall be reported to the Board President.  A violation of the agency’s confidentiality policy by a Board member shall constitute adequate cause for removal from office.
  6. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena.
  7. Information shall only be provided to an agency’s legal counsel in the event of litigation or potential litigation involving the agency.  Such information is considered privileged information, and its confidentiality is protected by law.
  8. State law mandates that suspected child abuse be reported to the Department of Children and Families or the police.  All workers are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.
  9. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party.  This may include a medical referral or a report to the law enforcement authorities.

The undersigned hereby grants permission for the youth to receive emergency medical treatment.


In the event of an accidental injury or illness while my child is under the supervision of Big Brothers Big Sisters of Connect or otherwise engaged in ay/all programming offered and coordinated by the agency, I authorize them to seek and obtain necessary medical attention for my child at a physician’s office or hospital.


I understand that every effort will be made to contact me immediately by using the contact information provided in this application.  Further, if I cannot be reached, I understand that every effort will be made to contact the secondary emergency contact person provided in this application. However, until I or my appointed emergency contact person can be reached, I authorize Big Brothers Big Sisters of Connecticut staff members to make decisions regarding the medical care of my child.


I acknowledge that I will be responsible for any medical expenses incurred as a result of this treatment.

Notice to parents/guardians/caregivers: 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 Connecticut on Big Brothers Big Sisters of Connecticut and NATIONAL websites, including ctbigs.org, bbbs.org, bbbsa.force.com, forms.bbbs.org, formassembly.com, formstack.i. Big Brothers Big Sisters of Connecticut COPPA statement is incorporated in the agency's Confidentiality and Digital Platform Policies detailed in this application. Big Brothers Big Sisters of Connecticut 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 provide us with permission. BBBS website accounts provide access to BBBS content, materials, and resources relating to BBBS programs and activities, including information pertaining your child's involvement with our porgramming.

You may revoke your consent at any time to refuse further collection and use of your child’s information. If you desire to revoke this consent, please contact our agency at program@ctbigs.org

Application Acknowledgement

I understand that this is an application for my youth to participate in program opportunities offered by Big Brothers Big Sisters of Connecticut and is not a promise or commitment by Big Brothers Big Sisters of Connecticut.

I certify that all information I have provided or will provide to Big Brothers Big Sisters of Connecticut, including this application, is true, accurate, and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would affect my application for a volunteer position. I understand that information contained in my application will be verified by Big Brothers Big Sisters of Connecticut. I understand that misrepresentations or omissions may be cause for my youth's immediate rejection as an applicant to or participant in the program, as well as immediately termination of any future mentoring relationships that may occur along with the youth's participation. 

At any time while involved with the Big Brothers Big Sisters program, I agree to immediately inform my Big Brothers Big Sisters contact person of any and all concerns I have about my child's participation in the program, as well as any new circumstances that may arise that may impact my child's continued participation in programming.  I understand that BBBS staff needs to be fully informed to provide the best guidance or support possible.  

Contact Information