Youth Application Template

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 year the youth will graduate.
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:






























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 [Agency Name] 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 [Agency Name], 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 
Big Brothers Big Sisters of Licking & Perry Counties
on 
Big Brothers Big Sisters of Licking & Perry Counties
and NATIONAL websites, including bbbslp.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. 
Big Brothers Big Sisters of Licking & Perry Counties
 COPPA statement is incorporated in the website Privacy Policy here: Big Brothers Big Sisters of Licking & Perry Counties 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 ETC.] 

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 Big Brothers Big Sisters of Licking & Perry Counties John Wilson /Executive Director Email- jwilson@bbbslp.org.

Confidentiality Policy


Big Brothers Big Sisters of Licking and Perry Counties (BBBSLP) respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.

 

Limits of Confidentiality:

  1. Information will be released to other individuals or organizations only with the client or volunteer’s written consent.

 

  1. Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteers request otherwise.

 

  1. For purposes of program evaluation, audit, or accreditation, and with 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 bodies shall be required to use information only for the purpose(s) stated in the approval action of the Board of Directors.

 

  1. Agency volunteers, student interns, and part-time temporary employees may have access to client and volunteer files upon authorization by the Executive Director, the Program Director, or designee(s). These individuals shall be required to adhere to the agency’s Confidentiality Policy. A Confidentiality Statement must be signed by these individuals prior to accessing confidential information.

 

  1. Information shall only be provided to law enforcement officials and the courts pursuant to a valid and enforceable subpoena.

 

  1. Information shall be provided to the agency’s legal counsel in the event of litigation or potential litigation involving the agency.

 

  1. State law mandates that suspected child abuse be reported to the Licking County Department of Job and Family Services.

 

  1. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself/herself or to others, necessary steps may be taken by the appropriate party. This may include a medical referral or report to law enforcement authorities.

 

  1. At the time that a child or volunteer is considered as a match candidate, information is shared between prospective match parties. The information about the volunteer may include: age, sex, race, religion, interests, hobbies, marriage/family status, sexual orientation, living situation, reason for applying to the program, and summary of why selected for the match. Information about the child may include: age, sex, race, religion, interests, hobbies, family situation, summary of clients’ needs, and expectations for match participation.

 

Safekeeping of Confidential Records:

 

  1. Copying, removing, allowing unauthorized access to any agency documents, files, mailing lists, or any form of distribution of client, volunteer, or personnel/staff information is not allowed.

 

  1. Case records shall be kept in a locked container.

 

Violations of Confidentiality:

 

  1. A known violation of the agency policy on confidentiality by a staff member shall result in disciplinary action.

 

  1. A violation of the agency policy on confidentiality by someone other than a staff member shall result in the offense being reviewed by the Board of Directors.

 

Clients or volunteers may request to view their individual record during regular business hours. Requests should be made, in writing, to the Agency’s Program Director.  Employees may request to view their individual record. Requests should be made, in writing, to the Agency’s Grants & Operations Director.

 

Contact Information