Youth Application

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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
Your file is closed. Please call our office at (412) 363-6100 if you have any questions.

Guardian Information | Informacion de padre o guardian 
Child's Information | Informacion de nino(a/e)
Street and Unit

Press CTRL while clicking to select multiple
Press CTRL while clicking to select multiple

If we are unable to reach you, who is someone else we could call who always knows how to reach you? Si no podemos comunicarnos con usted, A quien mas podríamos llamar y que siempre sepa como comunicarse con usted?

¿Si no podemos comunicarnos con usted, con qué persona nos podemos comunicar en caso de emergencia? 

Below are some questions to help our team get to know your child. Our goal is to match your child in the best mentoring relationship for them; the more you share with us, the better we will be able to create the right match for your child. Your answers to these questions have no bearing on your child's enrollment, they are just to help our team to get to know your child.

A continuación se presentan algunas preguntas para ayudar a nuestro equipo a conocer a su hijo/a. Nuestro objetivo es lograr que su hijo/a tenga la mejor relación de tutoría pará el/ella, cuanto mas comparta con nosotros, mejor podemos crear la combinación adecuada para su hijo. Sus respuestas no tienen relación con la inscripción de su hijo/a, solo sirven para ayudar a nuestro equipo a conocer a su hijo/a. 
Cuéntenos sobre la personalidad, las fortalezas y los intereses de su hijo.
Cual es la razón principal por la que desea que su hijo/a tenga un Mentor?
Que le gustaría que su hijo/a lograra como resultado de tener un mentor? Select up to 7 | Seleccione hasta 7
Cuales son algunas de las necesidades que tiene su hijo/a (por ejemplo, emocionales, sociales, conductuales o académicas) con las que un mentor podría ayudarlo?
Preguntas ara su niño/a.
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, marital status, sexual orientation, or religion. | Haremos todo lo posible para honrar sus preferencias para el mentor de su hijo. BBBS no discrimina por motivos de raza, etnia, género, estado civil, orientación sexual o religión.
Sabe su hijo/a que usted esta solicitando el programa?
Su hija/o desea participar?
Su hijo/a podrá reunirse con su mentor dos veces al mes durante el próximo año?
Su hijo/a tiene hermanos o parientes aplicando el programa BBBS en este momento o que estén actualmente en el programa?
Anticipa algún cambio significativo en su vida durante el próximo año o ha tenido alguno en el ultimo año? Seleccione todo lo que corresponda: los cambios de vida incluyen mudanzas, cambios de trabajo o cambios en el tamaño o la dinámica de la familia.
Tiene su hijo/a alguna de las siguientes condiciones que debemos conocer antes de participar en nuestro programa?
Otro condición:
Hay algún medicamento que un voluntario pueda necesitar administrarle a su hijo?
Cuales son las instrucciones para su uso?
Por favor enumere cualquier alergia alimentaria o ambiental que tenga su hijo/a.
Cuantas personas hay en el hogar? Nios y adultos
Below are questions specific to your household; answers to these questions will have no affect on your child's enrollment. We use this information to understand how to best serve the families in our program and in grant reporting. Any data collected is confidential; no identifying information is included in reporting materials.

A continuación, encontrará preguntas específicas para su hogar; Las respuestas a estas preguntas no tendrán ningún efecto en la inscripción de su hijo. Usamos esta información para comprender cómo servir mejor a las familias en nuestro programa y en los informes de subvenciones. Todos los datos recopilados son confidenciales; no se incluye información de identificación en los materiales de presentación de informes.
Recibe asistencia financiera?
Recibe servicios de sección 8 o de vivienda publica?
Su hijo es elegible para un almuerzo gratuito o reducido?
Ingreso anual del hogar
Tiene su hijo/a un padre / tutor con experiencia militar actual o pasada?
Esta el padre o representante desplegado con los militares?
Tiene su hijo/a un padre o representanted que este actualmente o haya estado encarcelado anteriormente?
Su hijo/a alguna vez ha sido arrestado o involucrado en el sistema de justicia juvenil? ( Responder si a esta pregunta no afectara la aceptación de su hijo/a en el programa Big Brothers Big Sisters).
Por favor explique?
Durante el ultimo año, su hijo/a ha tenido dificultades en la escuela?
Por favor describa?
Motivo/Razón de suspensión
Motivo/Razón de expulsión
Motivo/Razón del cambio de escuela
Otras áreas:
Su hijo/a recibe alguno de estos servicios?
Otros servicios

Bigs in Blue is Big Brothers Big Sisters of America’s one-to-one mentoring program that connects youth with police and other law enforcement professionals in communities across the nation, building strong, trusting, and lasting relationships.
Sometimes the best place to help a child realize their potential is at a school, community center, or corporate workplace. Whether mentoring occurs in the classroom, gym, or conference room, it’s all about developing a friendship, providing guidance and inspiring children to reach their potential. Students from a partnering college meet with their Littles at lunchtime or after school.

Expectations
  • Minimum of a one year commitment
  • Meet during the school year, with the opportunity to keep in touch through a writing campaign during summer break
  • Programs are supervised by Big Brothers Big Sisters staff or school/agency contact
You can give a child the invaluable gift of friendship by spending just a few hours together a couple times per month. To be a positive role model can be as simple as playing a board game, going to the playground, or participating in a BBBS activity. Just as your options are unlimited, so is a child’s potential.

Expectations
  • Make a one year minimum commitment to your Little
  • Make face-to-face contact with your Little at least twice per month
  • Participate in ongoing phone contact with Big Brothers Big Sisters staff throughout the duration of your match
Sometimes the best place to help a child realize their potential is at a school, community center, or corporate workplace. Whether mentoring occurs in the classroom, gym, or conference room, it’s all about developing a friendship, providing guidance and inspiring children to reach their potential. Must be at least 15 and a sophomore at a participating high school. Programs take place in an elementary or middle school during study hall or after school.

Expectations
  • Minimum of a one year commitment
  • Meet during the school year, with the opportunity to keep in touch through a writing campaign during summer break
  • Programs are supervised by Big Brothers Big Sisters staff or school/agency contact
mentor2.0 is a program developed in partnership with iMentor that brings technology-enriched, one-to-one mentoring to high school students.

Through collaborative efforts with schools, companies, and individuals, mentor2.0 provides high-impact mentoring relationships aimed at giving high school students the support and guidance they need to graduate high school and succeed in post-secondary education.

Expectations
  • Minimum 24 month commitment
  • Attend one in-person 2 hour event per month at Brashear High School
  • Participate in weekly online communication with your mentee via a web platform
Sometimes the best place to help a child realize their potential is at a school, community center, or corporate workplace. Whether mentoring occurs in the classroom, gym, or conference room, it’s all about developing a friendship, providing guidance and inspiring children to reach their potential. Students from Pittsburgh Public Middle Schools are matched with adult mentors from the community. Mentors visit once a week for an hour during the school year. Times vary depending on location.

Expectations
  • Minimum of a one year commitment
  • Meet during the school year, with the opportunity to keep in touch through a writing campaign during summer break
  • Programs are supervised by Big Brothers Big Sisters staff or school/agency contact
Sometimes the best place to help a child realize their potential is at a school, community center, or corporate workplace. Whether mentoring occurs in the classroom, gym, or conference room, it’s all about developing a friendship, providing guidance and inspiring children to reach their potential. Littles are matched with employees from our corporate partners who help foster college readiness and career development.

Expectations
  • Minimum of a one year commitment
  • Meet during the school year, with the opportunity to keep in touch through a writing campaign during summer break
  • Programs are supervised by Big Brothers Big Sisters staff or school/agency contact
Sports Buddies is a version of our Community-based Mentoring Program that matches adult mentors with youth who have a shared interest in sports, fitness, or just being active.

Expectations
  • Make a one year minimum commitment to your Little
  • Make face-to-face contact with your Little at least twice per month
  • Participate in ongoing phone contact with Big Brothers Big Sisters staff throughout the duration of your match
Big Siblings is a version of our Community-based Mentoring Program that matches adult LGBTQ+ mentors with youth also in the LGBTQ+ community. BBBS will host monthly group activities for matches in this program to attend. 

Expectations
  • Make a one year minimum commitment to your Little
  • Make face-to-face contact with your Little at least twice per month
  • Participate in ongoing phone contact with Big Brothers Big Sisters staff throughout the duration of your match
Level Up is an embedded mentoring program model at Dickson STEAM Middle School and South Brook Middle School. In this program, a Mentoring Specialist will work with small groups of students on topics related to sense of belonging, vision for future, avoidance of risky behaviors, and social emotional learning. All programming will occur at the school, facilitated and supervised by Big Brothers Big Sisters staff.



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;
For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports); 
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 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 Greater Pittsburgh 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 Greater Pittsburgh, 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.

The BBBS of Greater Pittsburgh respects the confidentiality of all clients’ (defined as caregiver/guardian/parent, child, and volunteer) records and, with the exception of situations listed below, shares information about clients only among the agency professional staff.  In order to provide 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 clients.  It is the agency’s responsibility to protect the confidentiality of reference responses and counseling reports by not disclosing their content to a client applicant.  Therefore, the agency may decide not to disclose the reason for rejection to the client.   

 

All records are considered the property of the agency and not the agency workers or clients themselves.  Records are not available for review by the clients.  Clients must sign this summary statement indicating an understanding of the agency’s confidentiality policy and agree to program participation under the guidelines before being accepted into the program.   

 

Information will be released to other individuals or non-BBBS organizations only with the client's written consent.  Identifying information regarding clients may be used in agency publications or promotional materials unless the client 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 client records.  Members of the Board of Directors or evaluators appointed by the Board have access to client 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 an 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. If an agency worker receives information indicating that a client 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 report to the local law enforcement authorities. 

 

At the time a child or volunteer is considered as a match candidate, information is shared by the agency with the prospective match parties.  The information about the volunteer may include such items as:  age, sex, race, religion, interests, hobbies, marriage, family status, sexual orientation, gender identification, living situation, etc.  Information about the child/parent may include such items as: age, sex, race, religion, interests, hobbies, family situation, sexual orientation, gender identification, living situation etc. 

 

I understand that some information, including opinions of the BBBSPGH staff, may be shared with parents of a potential Little or a potential volunteer.  I hereby give my authorization for such limited release and use of information that may otherwise be deemed confidential pursuant to the policies contained in the complete confidentiality policy statement and I release and waive any liability against the organization, all Big Brothers Big Sisters personnel and the Board of Directors of said organization.  

Signature
Acepto las políticas del programa, el comunicado de prensa y el código de conducta.
Escriba el nombre completo para firmar.

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Entiendo que al escribir mi nombre y hacer clic en "Enviar solicitud", estoy firmando electrónicamente este documento.