Big Brothers Big Sisters of Northcentral Wisconsin 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
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

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

Community-Based Mentoring

  • Who it’s for: Children ages 6–15 (matches can continue through age 19 if all parties agree).
  • How it works: Your child (Little) is matched one-to-one with a caring adult mentor (Big). They meet regularly in the community (2-4 times per month) for activities they both enjoy. This could be playing board games, going for a hike, attending a local event, or just spending time together.
  • Commitment: Volunteers commit to be a Big for at least a year, with the hope that friendships last much longer. Parents/guardians, volunteers, and the Little participate in monthly check-in calls (match support) with BBBS staff.
  • Focus: Builds confidence, friendship, and positive life experiences outside of school.
Site/School-Based Mentoring

  • Who it’s for: Children ages 6–15, referred by a parent, teacher, or counselor who feels they’d benefit from extra encouragement.
  • How it works: Mentors meet their Little at school once a week (for about 30 minutes to an hour) during the school day. They might play games, do crafts, talk, or work on school-related activities together.
  • Commitment: Bigs & Littles commit to be matched for a full school-year, with meetings happening only at school. Our staff conducts monthly check-ins with the Little at school and with the Big over the phone. Parent involvement is minimal - after the application process, you’ll just complete a few short surveys each year. Many of our school-based Bigs are High School students.
  • Focus: Supports self-esteem, attendance, and achievement while giving your child an additional caring adult role model at school.
Both programs provide your child with a trusted mentor, but the choice depends on whether you’d like the relationship to happen mainly in the community (with your involvement through monthly calls) or at school (with very little time required from you).




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





























Many guardians have preferences and sometimes that is regarding the race, religion, marital status, gender identity, and/or sexual orientation of a volunteer.

As BBBS does not discriminate on the basis of race, ethnicity, gender, gender presentation, marital status, sexual orientation, or religion, NONE of these things will disqualify a volunteer from serving with our organization. However, if you feel strongly that certain characteristics would not be the best match for your child, please describe your preferences in the box above.

We will make every effort to honor your preferences.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

Your Role:

To ensure that your child is getting the most of out their experience, our staff at BBBSNCW will also need to talk with you a few times throughout the year. We will attempt to contact you by phone and/or email. Please make sure to call or email us back. If you ever have any questions or concerns, please always feel welcome to get in contact with us. Match Safety: The safety of your child is our number one priority – no exceptions. Our staff carefully screen each volunteer during their enrollment process. To ensure your child’s safety we conduct monthly match support check-ins. Any information shared with the volunteer about your child is confidential. Volunteers should never be buying expensive gifts for your child. BBBSNCW staff are mandated reporters, we are required by law to report any suspected abuse or neglect. Our staff and volunteers are trained to respond if a child tells them about abuse. A report will be filed with authorities. All activities that your child and volunteer do together should always be age appropriate. Appropriate physical boundaries should always be maintained between your child and volunteer. They are allowed to give hand-shakes, high-fives and if both are comfortable hugs; once a relationship is established. A volunteer should never be tickling, wrestling, pinching, patting or asking/allowing your child to sit on their lap. Children and volunteers should NEVER be connecting on any type of social media platforms.

Confidentiality Policy


I understand that all records of Big Brothers Big Sisters of Northcentral Wisconsin are confidential. Records include, but are not limited to, all application materials, case supervision records and correspondence. The right to confidentiality applies not only to written records but also to video, film, pictures, and use of client or volunteer names in agency publications. In order to provide a service that is in the best interest of the children we serve, information from outside sources, including confidential references, must be assessed along with information gained from the clients and volunteers themselves. All records, including information from outside sources must be kept confidential and are therefore not available for review by the client or volunteer. 


I agree to adhere to the Confidentiality Policy described above and I agree to keep information discussed with me regarding a potential match confidential. I will not discuss this information with any person(s) other than the staff at Big Brothers Big Sisters of Northcentral Wisconsin. 


I understand that following acceptance into the program, a profile is developed for both the child and volunteer. Profiles contain information about family situations, motivations, interests, personality, and information that may have an effect on the relationship. These details will be discussed with both the parent, volunteer, and the child's school prior to and during a match. All potential match participants have the right to refuse to enter into a match based upon the information communicated. All elements of the profiles will be kept confidential except if our staff receive information from a Big, parent, or Little that is potentially harmful or illegal to either themselves, their families, their schools or the community at large. In addition, Big Brothers Big Sisters staff members are required to report any suspected abuse or neglect of a child. Our staff and volunteers are trained to respond if  a child tells them about abuse. A report will be filed with authorities.

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 Northcentral Wisconsin on Big Brothers Big Sisters of Northcentral Wisconsin and NATIONAL websites, including Big Brothers Big Sisters of Northcentral Wisconsin's website, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. 

Big Brothers Big Sisters of Northcentral Wisconsin 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.
 
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 BBBSNCW.org

Medical Release

I 
 do hereby authorize treatment by a licensed medical physician of the following minor in the event of a medical emergency which, in the opinion of the attending physician may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. 

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 Big Brothers Big Sisters of Northcentral Wisconsin 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. 

 

Parent/Guardian Agreement

I,
,legal parent or guardian of
("Minor Child")
hereby authorize Big Brothers Big Sisters of Northcentral Wisconsin, to exchange relevant information about my child with their school provided the school is within one of the following school districts: Abbotsford, Athens, D.C. Everest, Marathon, Merrill, Mosinee, or Wausau. The purpose or need for such disclosure is to allow BBBSNCW to:

  • Make the best possible match for my child
  • Provide services that meet my child's needs
  • Meet with my child at their school
  • Contact my child's teacher and other school staff to inquire about my child's schedule, attendance, and overall presence at school
  • Permit my child's assigned mentor (Big) to meet with them at school during school hours on a regular basis, until the match formally ends
This consent will remain in effect unless expressly revoked for the duration of the child's participation with Big Brothers Big Sisters of Northcentral Wisconsin unless I revoke it in writing.

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 Northcentral Wisconsin 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 Northcentral Wisconsin, 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.

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