PG/Little Enrollment Form

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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
This is the CHILD's Name
Enter a date in the following format: mm/dd/yyyy

Hold CTRL+F to select multiple

Only complete this box if your child has Tribal Affiliations
This is the year the youth will graduate.
This is the student's number from the school. If you don't have it please leave this field blank.
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, academic, behavior and attendance 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 Brothers Big Sisters of the Inland Northwest 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 the Inland Northwest, 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 Big Brothers Big Sisters of the Inland Northwest [an 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 the Inland Northwest on Big Brothers Big Sisters of the Inland Northwest and NATIONAL websites, including www.nwbigs.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of the Inland Northwest COPPA statement is incorporated in the website Privacy Policy here: 
https://nwbigs.org/privacy-policy/

Big Brothers Big Sisters of the Inland Northwest 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 joinus@nwbigs.org.

Medical Release

In the event that a youth is involved in an accident/injury during a match activity or program event, parent/guardians will be notified by Big Brothers Big Sisters staff/mentor immediately. 

In the event that my child is injured or becomes seriously ill and I cannot be reached, I authorize Big Brothers Big Sisters, their staff or partners, or their designee, to seek and authorize any and all hospital, medical, dental and surgical treatment deemed advisable by the circumstances. I also authorize my child to be transported by ambulance or aid car to an emergency center for treatment. 

I hereby agree to release Big Brothers Big Sisters of the Inland Northwest, its members, directors, staff, or other supportive personnel from all liability so long as such injury i no cuase intentially by Big Brothers Big Sisters of the Inland Northwest, its members, directors, staff or other supportive personnel. 

My signature on this document acknowledges that I have read and understood the abovce information on the benenfits provided by Big Brothers Big Sisters of the Inland Northwest. 
Big Brothers Big Sisters of the Inland Northwest does not provide insurance covering activities, injuries, death or dismemberment of participants in our program. By agreeing to paricipate in our program you hold harmless Big Brothes Big Sisters of the Inland northweest, their members, affiliates, staff and board. 

Volunteers with BBBS ar required to hold and manintain current Auto Insurance meeting the required minimum identified by law. 

As the Parent/Guardian for the child in this enrollment form, I will hold and keep current the following insurance for my child for the duration of time my child is participating in programs with Big Brothers Big Sisters. Participation in Big Brothers Big Sisters is at my own risk. 

1. Personal insurance for injuries and illness. 

Confidentiality Policy

As a potential participant of Big Brothers Big Sisters (BBBS).  I understand I have access to confidential information about youth, families or volunteers. I fully understand and accept the responsibilities inherent in my role to maintain the complete confidentiality of all personal information, documents and parties who are engaged in this partnership (collectively, the “Confidential Information”), including myself, BBBS and all its affiliates, employees and volunteers, public figures, as well as, all youth and families served by this partnership. The obligation of confidentiality persists indefinitely and is not limited to the period of time beginning with my participation in BBBS and ending at the close of my participation. 

In order for BBBS to provide responsible and professional services, it is necessary for volunteers, youth and parent/guardians to disclose personal information. BBBS respects the confidentiality of information. Confidentiality applies to written records, electronic records, voice, verbal statements, pictures (motion or still) and the use of student/mentor’s name in agency publications. All records are considered property of the agency, not of agency staff, partner agencies, youth, parent/guardians or volunteers. 

I further agree to the following terms: 

 In the event an actual breach of confidentiality or a release of Confidential Information has occurred or if a situation which I reasonably believe may result in a breach of confidentiality comes to my attention, I agree to immediately notify the designated BBBS representative and/or any other appropriate BBBS staff member. I understand and agree I am required to report such breach or threatened breach of confidentiality regardless of whether the breach is caused by my own actions or by the actions of another person. 

According to the Confidentiality Policy, information from youth/volunteer records may only be shared with individuals/organizations as specified. 

Identifying information regarding youth/volunteer may be used in agency publications or promotional material only if the youth/volunteer has given written permission. 

Information shall be provided to law enforcement or courts only with a valid, enforceable subpoena. 

Information shall be provided immediately to BBBS staff if child abuse, exploitation or neglect is to be reported. 

Information shall be released to Child Protective Services and law enforcement where child abuse is suspected  

If agency staff receives information indicating a youth/volunteer/PG may be dangerous to himself/herself/them or to others, steps shall be taken to protect the appropriate party, including a report to the law enforcement authorities. 

Information shall be provided to the BBBS legal counsel in the event of litigation or potential litigation involving the agency/BBBS. Such information is considered privileged information and the law protects its confidentiality.  

When a youth/volunteer is considered for a match, information is shared between the prospective parties. The identity of the parties is not revealed until after the parties agree to the match. Each party has the right to refuse the proposed match based on the anonymous information provided. Information shared may include: age, sex, race, religion, education, interests, hobbies, marriage and family status, living situation, sexual orientation, reasons for applying to the program, expectations for match participation, a summary of the reasons an individual was chosen for the match, and all other information deemed relevant. The individuals to whom the information is provided shall agree not to share the information with any other person. 

Certain outside bodies, including members of the Board of Directors, may have access to youth/volunteer records for the purposes of program evaluation, audit, accreditation, and/or for purposes of operating and making available approved software, on-line sites and login portals. All such authorized persons and representatives shall enter into a Confidentiality Agreement before receipt of any information from youth/volunteer records.  

Other than in the instances set forth above, information from youth/volunteer records shall not be released unless accompanied by an authorized consent to release information form signed by the represented party. If the youth is under the age of 18, the consent to release information form must be signed by the parent or guardian. 

 

Thank you for your careful consideration and willingness to uphold the privacy and confidentiality of those participating in BBBS. 

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

VALUES 
It is important all match parties respect the different values and views each brings to the match relationship. 
 
 REPORT OF ABUSE 

As mandatory reporters, we are required to follow WAC code regarding the reporting of abuse of children.   

It is required to disclose the following to BBBS staff immediately: 
a. If any party of the match is a danger to himself/herself or someone else. 
b. If any party of the match discloses physical, sexual, emotional abuse or neglect. 
 
Youth and Parents/Guardians are trained by our agency in safety education and to understand what behavior is appropriate from adults.  
 
Viewing any sort of suggestive materials (i.e. magazines, pornography, videos, etc.) at any time around the Youth is strictly prohibited.  
  

DISCIPLINE 

The Big is a friend, not a PG. The Big will not become involved in the discipline of the child on behalf of the PG. The Big is expected to respond appropriately if the Youth misbehaves during their match time. Any demeaning, shaming, threatening, or exploitative behavior by the Big is never permissible. 
 
The PG will not deprive the Youth of time with Big as a means of discipline. 
 
BOUNDARIES 

  • Inappropriate language or gestures should not be used around the Little. 
  • All parties must wear appropriate attire at all times.  
  • Little must have their own space to shower, bathe/dress.  
  • Big is not a therapist or authority figure.  
  • PG will not discuss problems with the Big outside of those which may affect the time with the Youth. If additional support is needed beyond this role, the PG should consult the PS.  
  • Big will limit time spent at the Youth's home. This will avoid involvement with other family members and keep the relationship between Big and Youth in tact.  
  • PG will not hire or ask the Big for household assistance or babysitting. 
  • PG and Big will avoid all business and financial transactions with each other, including financial loans.  
 
SCHEDULING/OUTINGS 
  • Big clears schedules with the PG.   
  • Big will keep PG informed about where they are going, timeline for outing, and how to reach them if needed.  
  • Match time is for the Big and Youth. Additional members of the family and friends should not be included except on rare occasions.  
  • The Big and Youth should not see each other more than once or twice a week. Each party needs to have time for their own families, friends and outside activities.  
  • Outings to the Big's home are not allowed in the first 6 months of the match. A home assessment is required before the Youth can visit the Big's home.  
  • Overnight outings are not allowed.  
  • Out of state outings, except to Northern Idaho/Eastern Washington, must be cleared by the Program Specialist. 
  • Out of Country outings are not allowed. 
 
OBEYING THE LAW 
The Big is required to comply with all local, state and federal laws. Including car seat safety laws and distracted driving laws. 
 
ACTIVITIES 
Watercraft/Watersport: lifejackets must be worn when in/on a watercraft or any sort or being pulled behind a watercraft of any sport, motorized or not. 
 
Helmets: must be worn by all parties when bicycling, rollerblading, roller skating, ice skating, motorcycling, skateboarding, snow boarding/skiing, scootering, rock climbing, and using All Terrain Vehicles and snowmobiles.  
 
Movies: No "R" rate movies, video games or television shows. No "PG-13" movies, video games or television shows if Youth is under age 13.  
 
ALCOHOL/TOBACCO/DRUG USE 
Use of Alcohol, Tobacco, E-cigarette and drugs (legal or not, including marijuana) is prohibited during the time the Big and Youth are together. Prescription drug use with no resulting impairment is the exception. 
 
Use of drugs (including personal prescription medications and OTC drugs such as cold medicine) prior to the match activity is not allowed if it will impact/impair the match activity or safety of the Youth while attending the match activity. 

LEGAL RESPONSIBILITY 

The Big assumes no legal responsibility resulting from the relationship with the Little/Student. If a family problem arises, financial or otherwise, the youth or PG may contact their Program Specialist (PS) for assistance. 
 
PROGRAM PARTICIPATION 
The Big, PG and PS will work together on the goals of the match. All must be active team members. 
 
The B/M, PG and L/S/Y will complete all required support calls to stay in compliance with the program standards. 
The B/M, PG and L/S/Y will complete all surveys to stay in compliance with program standards. 
Notify BBBS if your residence, telephone number, school or place of employment changes.  

       
          DISREGARD OF GROUND RULES 
 Any disregard of the above ground rules, or any willful misrepresentation of information given to the agency by the Mentor will result in immediate review and possible closure from the program.

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