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Big Brothers Big Sisters of Westchester and Putnam

 Youth Application

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
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 youth's current year
Guardian Information
Type NA if unemployed
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?

Additional Questions




Other Siblings and Relatives in the Program
Please choose this child's relationship to the following people:



Examples of significant life changes include moving, job changes, or changes in family size or dynamics.
















Answering yes to this question will not affect your child's acceptance into Big Brothers Big Sister program










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 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 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 Brother Big Sisters of Westchester & Putnam 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 Westchester County, 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.

Photo Consent and Release Form

I,
,legal parent or guardian of
("Minor Child"), irrevocably consent:
For myself and Minor Child to any and all uses and displays of my or Minor Child’s name, image, likeness, appearance, basic biographical information, audio/video recordings, writings, artwork, and the like, in original form or in modified form, in whole or in part, in, on, or in connection with merchandise, advertising, publicity, marketing, fundraising, and the like, in printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America and [BBBSA affiliate] in their sole discretion, and by any of their affiliates, successors, partners, sponsors, donors, any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type, and any other authorized third parties, without further consent from me or Minor Child, without any royalty, payment, or other compensation to me or Minor Child, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use (the “Released Material”). In consideration of the mutual promises made herein, and for other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I hereby grant to BBBSA and its affiliates the right to use the Released Material as BBBSA and/or its affiliates may desire, in all media now existing or hereafter created and in all variations and forms including, but not limited to, internal or external publications or productions, informational or recruitment materials, marketing materials, fundraising materials, televised photography and/or recordings, advertisements, Public Service Announcements, and/or online and social media sites. The use of this information shall be at the sole discretion of BBBSA and/or its affiliates. I further grant to BBBSA and its affiliates the absolute right to use the Released Material in whole or in part, alone or in conjunction with any other image, name, writings or reproduction, in color or otherwise, for art, advertising, business, trade, or any other lawful purpose whatsoever, in perpetuity throughout the world. I understand and agree that all materials created by BBBSA and/or its affiliates that use the Released Materials are the property of and are owned by BBBSA, and that I cannot authorize their use by any other party. I further understand that BBBSA may authorize their use by a third party. I hereby irrevocably transfer and assign to BBBSA my entire right, title and interest, if any, in and to the Released Materials and all copyrights in the Released Materials arising in any jurisdiction throughout the world, including the right to register and sue to enforce such copyrights against infringers. I acknowledge and agree that I have no right to review or approve the Released Materials before they are used by BBBSA and/or its affiliates, and that BBBSA has no liability to me or Minor Child for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSA’s and/or its affiliates’ editing, alteration or use of the Released Materials. BBBSA has no obligation to use the Released Materials or to exercise any rights given by this Consent and Release Form. I hereby release BBBSA and its affiliates, employees, and agents, as well as any partner companies, from all claims, demands or liabilities and related financial costs that I or Minor Child may now or hereafter have arising in connection with BBBSA’s exercise of the rights hereby granted, and/or with the appearance or the Released Materials in any publication or production. These include, without limitation, claims for compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever. 

 

COPPA Parental Consent Form

Notice to Parents 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 BBBS of Westchester & Putnam on BBBS of Westchester and Putnam and NATIONAL websites, including bigswestchester.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. BBBS of Westchester & Putnam COPPA statement is incorporated in the website Privacy Policy here: Big Brothers Big Sisters of Westchester County 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 to matches and other programs.  

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 [Agency contact info here].

Medical Release

The agency’s professional staff shall report suspected child abuse to law enforcement authorities when the staff knows or has reasonable cause to suspect that a client is an abused or neglected child. In addition, if the alleged offender is a Big Brother or Big Sister, the board president, legal counsel, BBBSA, and the agency’s insurance carrier will be notified. The match will be suspended immediately.

Should the agency professional staff receive information that a client or volunteer may be dangerous to self or others, the Vice President or Chief Executive Officer (CEO) may authorize any Agency worker to take steps necessary to protect threatened individuals, including but not limited to making a medical referral or a report to law enforcement authorities. Clients and volunteers shall consent to this provision.

Confidentiality Policy

In order for Big Brothers Big Sisters of Westchester & Putnam to provide responsible, professional service to clients, it is necessary for volunteers, clients, and parents or guardians of clients to divulge extensive personal information about themselves and their families. The agency respects the confidentiality of client and volunteer records. Such personal information about clients and volunteers shall be shared only among the agency's professional staff, with the exception of the specific situations described below.

Limits on Confidentiality

Except as otherwise provided herein, confidential information concerning volunteers, clients, and parents or guardians of clients may be released to or obtained from other organizations or persons only upon written consent to release/obtain such information by the affected volunteer, client, or parent/guardian. Information will be shared in summary form. Duplicates of agency records will not be shared

Identifying information concerning volunteers and clients may be used in agency publications or promotional material upon consent, written or oral, by the volunteer or client

For purposes of program evaluation, audit or accreditation, and with the prior written approval of the Board of Directors, certain outside bodies, such as Big Brothers Big Sisters of America, may be granted access to client and volunteer records. These outside bodies shall follow this Agency policy on confidentiality. Outside bodies shall use such information only for the purpose(s) stated in the approval action of the Board of Directors.

Client and volunteer information shall only be provided to law enforcement officials or the courts by the CEO pursuant to a valid subpoena.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

Guidelines and Ground Rules



The following are ground rules expected of all Big Brothers, Big Sisters and Parents/Guardians.  It is important that they be followed for the benefit of the match. 


Match Support and Match Expectations: 


  • Check in with your Program Manager within two weeks of the match meeting, and then monthly during the first year.  Contact in subsequent years will be once every three months.  Keep the agency and each other informed of any changes that may affect the match. 
  • Parents/Guardians and BB/BS's are expected to use the services provided by Program Managers when problems or the need for support arises.   

Your first match support contact is due 2 weeks from matching date. 

  • You will be asked to complete an evaluation of the match relationship within the first three months of your match, and at each year anniversary. These may be done in the office or over the telephone with your Program Manager. 
  • Matches will get together for a minimum of 4 to 6 hours a month, for a commitment of no less than a year unless otherwise agreed upon by the BB/BS, LB/LS, parent/guardian, and Program Manager. 
  • Parents/Guardians should not prevent their child from seeing their BB or BS as a form of punishment.  This relationship is intended to be a regular part of the child’s life – not a “reward for being good”. 
  • It is the parent’s/guardian’s responsibility to help the child keep their scheduled appointments with their BB or BS.  If it is necessary to cancel an appointment, the reason should be explained as far in advance as possible, and the date should be rescheduled for the earliest possible time. 
  • Your child’s BB or BS is not:  a babysitter, a taxicab service, or someone to run errands for you. Please do not treat them as such. 
  • Remember that the BB or BS is a volunteer.  It is important to let the volunteer know that he or she is appreciated.  Encourage your child to make occasional phone calls, say thank you, etc. 
Safety Awareness:

  • I acknowledge that my child and I have participated in the Safety Awareness training (at the interview) with a member of the Big Brothers Big Sisters staff. I acknowledge my role in protecting my child from abuse as discussed in the training. 
Activities at Big’s Home & Overnight Match Activities: 

  • No match activities/outings are permitted in the BB/BS’s home within the first six months of the match. At the six month mark, your BBBS program manager will discuss with you this option if you so choose to permit your child.   
  • No overnight visits are permitted.  
  • I clearly understand that Overnight Visits are prohibited and agree to adhere to the guidelines.    
Boundaries & Communication: 
  • Honest communication between the BB/BS and the parent regarding finances is essential!  The emphasis should be on the relationship, not on the money spent on activities.  It is recommended to plan activities that cost little or nothing.  Gifts should be limited to a few times per year and should not be excessive. 
  • Remember, the match relationship is between your child and his/her BB or BS.  Don’t ask that siblings or yourself be included in outings.  Parents and volunteers are not allowed to date each other. 
  • Encourage your child to call his/her Big Brother/Sister on a regular basis, as it takes both of them to make a friendship. 
  • The parent/guardian should not discuss his/her own problems (whether or not they have to do with the child) with the BB/BS.  If necessary, the parent may call the Program Manager for an appropriate referral. 
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