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. 
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Dear Parent or Guardian,

Your child is eligible to participate in the Big Brothers Big Sisters of Ventura County (BBSVC) High School Mentor program. This program provides a carefully screened and trained high school student volunteer who will mentor and work with your child. The mentor and your child will spend one hour a week working on homework and participating on enrollment activities at your child's school. Please complete this form so that your child is eligible to participate in the program.
Youth Information





Enter a date in the following format: mm/dd/yyyy













Please do not use a school email.

Referring Parent/Guardian Information





















Type NA if unemployed










Is your youth or their family involved in or receiving any of the following services?

List all children under 18 in the primary household where the youth lives:





Local Emergency Contact Name/Relationship to Youth (other than parent/guardian):










BBSVC Programming

Talent Release
Summary: Permission to use youth’s image and/or name in photos, videos, and other media
related to their experience with Big Brothers Big Sisters of Ventura County.

I consent for all purpose to the reproduction and/or use of media with my youth’s image (with or
without the use of their name) by Big Brothers Big Sisters of Ventura County (BBSVC) and by
any nominee or designee of BBSVC – including any agency, client, periodical, or other
publication – in all forms and media, and in all manners, including advertising, trade, display,
editorial, art, and exhibition.

In giving consent, I release BBSVC, their nominees, and designees from liability for any
violation of any personal or proprietary right I may have in connection with such reproduction or
use.
General Outing Consent
Summary: Permission for youth to participate in general, BBSVC-related match outings with
their mentor under BBSVC’s liability policy.

I give my permission for my youth to participate in the general outings with the volunteer
assigned to my youth by Big Brothers Big Sisters of Ventura County (BBSVC). Realizing that
volunteers are serving to the best of their ability and in consideration of the benefits which may
be derived by my youth through Big Brothers Big Sisters of Ventura County, I hereby voluntarily
wave any claim against Big Brothers Big Sisters of Ventura County, for any and all causes which may arise in connection with the activities described above. 

If during an activity my child should become ill or sustain injury, I hereby authorize the Big/mentor to obtain emergency care for them.

Professional Disclosures

Summary: The disclosure of records authorized herein is required to determine this youth's
suitability for involvement in the Big Brothers Big Sisters of Ventura County (BBSVC) mentoring
program as a mentee. This consent is subject to revocation by the undersigned at any time
except to the extent that action has been taken in reliance hereon, and if not revoked, it shall
terminate on the termination of the match and/or closure of the youth’s case file without express
revocation.
Release of School Evaluation (Teachers & Counselors)
Release of Therapy Evaluation

Application Agreement & Understanding

The services of Big Brothers Big Sisters of Ventura County (BBSVC) are furnished without
regard to race, religion, national origin, color, gender, identity, marital status, sexual orientation,
financial status, or [dis]ability. However, such factors are considered in selecting an appropriate
mentor for a youth. The following questions are designated to satisfy this policy in addition to
fulfilling additional requirements for funding purposes. Your information will be treated with care
and confidentiality. Your name or identifying information will not be attached to reported data.

Big Brothers Big Sisters of Ventura County (BBSVC) is a social service program designed to
help youth who have shown a need for a reliable relationship with a positive adult role model.
While this program reflects interfaith, interracial, and identity diversity, the requests of both the
youth and their parent/guardian are respected in the selection of the appropriate adult
volunteer for each youth.

In determining whether an applicant may be considered for a match and what information shall
be communicated to each party involved in any prospective match, due consideration must be
given to past and present factors in the health, personality, sexual orientation, and behavior of
each individual and/or family constellation which professional BBSVC personnel deem may
have a significant effect upon the relationship, and which, if revealed at a later date, might affect
it adversely. Relevant information shall be provided, however, the name or names the parties
described shall be held confidential before a match is made. Any party has the right to refuse
to enter a match based upon the information so communicated.

The assessment interview is designed to establish a profile of your youth and their
interests. This profile will be used by BBSVC to determine your youth’s suitability for service
and if it is deemed by the professional staff and/or the governing board of BBSVC that your
youth is suitable, they will be matched with a volunteer mentor (a “Big”). Except for the Big
applicant who has been pre-screened and is actively being considered for a match with your
youth, all elements of your youth’s profile will be kept in the strictest confidence. Prior to any
assignment to a Big, a profile of the volunteer will be discussed with you to ensure your youth’s
interests will be respected.
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