Short-term or One-time Programs Mentee Application & Consent Forms

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Application Details

This application is for youth interested in participating in short-term or one-time mentoring opportunities through Big Brothers Big Sisters of Rhode Island. These experiences are designed to provide meaningful, skill-building connections with positive adult role models without the commitment of a traditional long-term Match. Opportunities may include vacation camps, group sessions, workshops, community events, or single-day programs focused on topics like leadership, career exploration, social-emotional learning, and enrichment activities. Participants will have the chance to build confidence, develop new skills, and form supportive connections in a structured, supervised environment.

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

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Youth Information

First Name

Last Name

Middle Name

Preferred Name/Nickname

Birthdate

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

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?

Race/Ethnicity

American Indian or Alaska Native	Asian - Chinese
Asian - Filipino	Asian - Indian
Asian - Japanese	Asian - Korean
Asian - Other	Asian - Vietnamese
Black or African American	Hispanic - Cuban
Hispanic - Mexican,Mexican American,Chicano	Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican	Middle Eastern or North African
Pacific Islander - Chamorro	Pacific Islander - Native Hawaiian
Pacific Islander - Other	Pacific Islander - Samoan
White or Caucasian	Other
Prefer not to say

Nationality/Country of Origin:

Hold CTRL+F to select multiple

Tribal & Regional Corporation Affiliations

School

Grade

This is the year the youth will graduate.

School Account ID

12-Grade

Youth's Email

Youth's Phone

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Preferred Name/Nickname

Parent/Guardian Gender/Gender Identity

How do you identify?

Parent/Guardian Personal Pronouns

What pronouns do you use?

Mobile Phone

Home Phone

Personal Email

Employer

Type NA if unemployed

Guardian's Relationship to Youth

Do you have legal custody of this youth?

YesNo

Family Information

Youth Living Situation

Living Situation Description

Languages Spoken in the Home:

English	Spanish
African Languages (Swahili, Bantu)	American Sign Language
Arabic	Asian: Other
Chinese	Creole
Dutch	Eastern European (Czech, Slovak)
French	German
Greek	Hebrew
Hmong	Indian (Hindi, Punjabi)
Italian	Japanese
Keres (West)	Korean
Nordic	Persian
Portuguese	Russian
Turkish	Lao

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

State

Zip Code

Emergency Contact

If we are unable to reach you, who is someone we could call who always knows how to reach you?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Additional Questions

Which program are you enrolling your youth into?

STEAM April Vacation CampThe Little Brotherhood at Buttonhole

What is the primary reason for you wanting your child to participate?

Please provide a list all of individuals allowed to pick up your child from the program. Include their First Name, Last Name and Phone Number:

Does your child want to participate?

YesNo

How did you hear about Big Brothers Big Sisters?

Referral Detail ID

Other Siblings and Relatives in the Program

Please choose this child's relationship to the following people:

Name:	Relationship:
Application/Enrollment ID	Contact ID

Does the youth have any allergies?

YesNo

Allergies Description

Is the youth taking any medications?

YesNo

Medications Description

Does your child have any medical conditions that might affect them in participating in activities?

YesNo

Pertinent Medical History

Do you (parent/guardian) receive public income assistance at this time?

YesNo

Do you (parent/guardian) receive assistance with housing (e.g. Section 8, residence in public housing)?

YesNo

Is your child eligible for free or reduced lunch?

YesNo

Annual Household Income (total income of the adults the child lives with)

Has your child ever been arrested or involved in the juvenile justice system?

YesNo

What was their involvement?

Within the last year, has your child been in trouble at school?

Poor grades	Skipping school/classes
Behavior problems	Has been suspended
Has been expelled	Sent to an alternative school
None

Please describe:

Does your child receive any of these services?

Special education	Speech therapy
Tutoring	In-school counseling
Other counseling	None

Please describe:

What strengths does your child have that this program could help grow?

What are some of the needs your child has (examples could be emotional, social, behavioral, or academic) that this program may be able to help them with?

Parent/Guardian Agreement

By checking the box below and providing my signature at the end of this form, I give permission:

I am enrolling my child in, and granting permission for my child to participate in, BBBSRI’s mentoring programs, short term and one time programs, events, and activities.
My child will participate in an in-person intake interview conducted by Big Brothers Big Sisters of Rhode Island staff and will complete questionnaires throughout their time in the program that may include questions about school, home life, and personal interests.
My child will speak with a Big Brothers Big Sisters of Rhode Island staff member about personal safety.
Big Brothers Big Sisters of Rhode Island is not obligated to match my child and may deny an application or close a match at any time. To protect the confidentiality and safety of all participants, the agency is not required to disclose the reasons for such decisions.
I agree to timely communication and follow-up with agency staff as required.
I agree to complete surveys during my participation in the program to support evaluation and continuous improvement of services.
It is my responsibility to notify the agency of any changes to the information provided during the application or enrollment process (including, but not limited to, address, phone number, auto insurance status, or new criminal charges).
I understand that certain relevant information about me, my family, and my child may be shared with a prospective volunteer mentor for matching purposes. This may include demographic information, preferences, and information relevant to my child’s safety and well-being.
I understand that disclosures of suspected child abuse or neglect, past or present, made to BBBSRI staff will be reported to the appropriate authorities in accordance with mandatory reporting laws.
I understand that the information I provide during the enrollment process will be kept confidential, unless disclosure is required by law.
As part of the enrollment process, I will be required to provide additional personal information, including participation in an in-person interview.
I consent to my child being transported to BBBSRI-approved events and match activities by their assigned volunteer mentor, who has been screened and approved by Big Brothers Big Sisters of Rhode Island (Community-Based Mentoring only).

I accept the terms and conditions

Media Release for Youth Participation

I, as parent and/or guardian of the identified minor child in this application, grant irrevocable and unrestricted right, authority, and license to Big Brothers Big Sisters of Rhode Island (BBBSRI) to:

· Interview, discuss, and/or record me whether by video, audio, photographic, print, digital, internet, or other media (“Recordings”) and use and/or feature any and all such Recordings;

· Use and/or feature any and all video, audio, photographic, print, digital, internet, or other media which I provide to BBBSRI or post or disseminate publicly (“Media”);

· and Use, feature, and/or identify my name, image, likeness, and/or voice consistent with the mission of BBBSRI including, but not limited to, in relation to advertising, marketing, fundraising, promotional, and educational purposes.

I further release BBBSRI from any and all claims and liability, and waive the same, arising out of the rights, authority, and licenses granted herein.

BBBSRI will use any such rights, authority, and licenses granted herein to support, advance, and promote the mission of BBBSRI. Should I desire to restrict the rights, authority, and licenses granted herein, I agree and understand that I must make a specific request in writing to the CEO of BBBSRI. I agree and understand that BBBSRI is under no obligation to agree or respond to my request. I agree and understand that BBBSRI must affirmatively agree in writing to any restriction of the rights, authority, and licenses granted herein.

I have read this form fully, and I agree to and understand its terms. I am signing this form voluntarily, and I agree and understand that my choice is legally binding. I (choose opt in or opt out below) to BBBSRI using my childs images and first name in promotional materials including social media and videos.

Opt InOpt Out

Informed Consent

What to Expect

Big Brothers Big Sisters of RI mission is to create and support one-to-one mentoring relationships that ignite the power and promise of youth. Participation in our Program is voluntary. However, it is expected that all participants are able and willing to commit to our Program, at least for a period of 18 months.

Risks

Before giving your consent to participate in our Program, it is important that you are informed of possible risks:

Participants understand that the program is not obligated to match their child with a volunteer, and that as part of the enrollment process they will be asked to provide additional information through an in-person interview.
Participants understand that certain relevant information about their 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).
Participants understand that their child may be matched to a mentor within weeks, or it may take months, dependent on mentor pool available and expressed personal preferences.
Participants understand that the information they provide in the enrollment process, in person or virtually, will be kept confidential, unless disclosure is required by law and with exceptions noted (see limits to confidentiality below).
Participants understand that their match may close prematurely.

Social Media

Program staff are prohibited from engaging in a personal and virtual relationship, via social media outlets (Facebook, Instagram, Tik Tok, Snapchat, etc.) with Program participants (Bigs, Littles & families). Additionally, Mentors, Mentees/families are prohibited from engaging in a virtual relationship, via social media outlets (Facebook, Instagram, Tik Tok, Snapchat, etc.), between each other.

Records

Legally and ethically, we are required to keep records of all our interactions with participants. Records are considered the property of BBBSRI. Participants' personal records are stored in a secure national database and only authorized staff have access to those records. Legally, you have right to see all information generated between us. You must provide explicit permission for information to be revealed, unless the law specifies otherwise (see exceptions to confidentiality). Thus, with your written consent, we will provide information to anyone with legitimate need. You are also entitled to a copy of any records generated by BBBSRI. BBBSRI keeps records for 7 years past the date of the last contact. Then, because of space and privacy concerns, records are destroyed in compliance with state law and professional ethics.

Rights and Responsibilities

YOU HAVE CERTAIN RIGHTS AS A CLIENT/PARTICIPANT OR AS A PERSON REQUESTING SERVICES FROM BIG BROTHERS BIG SISTERS OF RHODE ISLAND (BBBSRI).

YOU HAVE THE FOLLOWING GENERAL RIGHTS:

To be informed of your rights during orientation/enrollment, whenever BBBSRI makes a change in the rights of persons served, and upon your verbal or written request.
To be encouraged and assisted throughout services to exercise your rights and to voice opinions and recommendations about services and policies offered by BBBSRI without fear of discrimination, restraint, interference or recrimination.
To receive services in a language and manner you can understand.
To be informed, verbally and/or in writing, of what is expected of you as a client.
To receive assistance in resolving issues and assistance in accessing alternative services.

YOU HAVE THE RIGHT TO SERVICE PROVIDED WITH RESPECT, DIGNITY, AND PRIVACY:

To receive services that are considerate and respectful of your values and beliefs.
To privacy, security and confidentiality of information, as specified by all Federal and State laws and BBBSRI policy.
To receive services in an environment free of abuse, neglect, mistreatment, financial exploitation, threats, and/or any human rights violation, as well as to be protected from any and all forms of coercion.

YOU HAVE THE RIGHT TO BE INFORMED OF AND PARTICIPATE IN TREATMENT AND/OR SERVICE DECISIONS:

To be informed of the policies, changes and addendums, regarding informed consent to participate in the agency’s services.
To be informed about what to expect during the program and/or service process.
To be informed about, and to participate in, decisions regarding services and to receive, at minimum, the information to facilitate informed decision-making, including limitations on confidentiality; ongoing progress/status regarding program goals and objectives, services or interventions, when appropriate; projected end date of services.
To terminate services/program participation at any time.

YOU HAVE THE RIGHT TO YOUR CLIENT RECORD INFORMATION:

To provide authorization or to refuse to provide authorization for the release of confidential information to family members, service providers, except when BBBSRI is required by applicable state and federal law to disclose such information.
To receive a copy of all authorizations for release of confidential information that you have approved.

YOU HAVE THE FOLLOWING RESPONSIBLITIES AS A CLIENT/PARTICIPANT OF BBBSRI:

To provide accurate information about yourself and your child or children that is relevant to your participation in the program.
To be familiar with your rights and responsibilities.
To attend and participate in all appointments (interview/ match support), in person or via phone, or give adequate prior notice of cancellation.
To speak and engage with my Match Support Specialist as often as required and will return phone calls within 24-48 hours.
To comply with the rules of the specific program to which you are assigned.
To treat other participants and staff respectfully.
To respect the privacy of other participants.
To act as an ambassador of BBBSRI programs and to represent yourself and the agency if a positive manner.

A copy of Client Rights and Responsibilities is provided to you when you begin receiving services. A copy may also be obtained by calling (401) 921-2434 Ext 101.

Client Code of Conduct

Big Brothers Big Sisters of RI (BBBSRI) adopts this Code of Conduct to define acceptable standards of behavior for Parents/Guardians, Littles, and Bigs (participants) and to provide a procedure for action whenever there are grounds to end services because participants have engaged in disruptive and/or unacceptable behavior.

As documented on the Rights and Responsibilities contract, BBBSRI is responsible for providing all participants with a rewarding and safe environment. Therefore it is expected that all participants will:

Treat staff, families, volunteers and other participants with respect & honesty.
Refrain from discriminatory comments or actions in regards to sexism, racism, ableism, classism, homophobia, biphobia, transphobia and any other behavior that is derogatory to a marginalized person(s) in our community.
Inform staff of needs and changes in circumstances in order to receive relevant services.
Understand that BBBSRI works with many individuals with many levels of needs, and staff may need to prioritize their time to deal with emergency or high need situations.
Maintain confidentiality of other clients, volunteers and staff.
Understand that BBBSRI and its staff has limitations in regards to the services they provide.
Realize that access to services may have limits and eligibility does not automatically ensure services.
Deal with problems and concerns in a mature manner according to BBBSRI Policies and Procedures.

Refusal of Service

Participants have a responsibility to be respectful and considerate of other participants, and staff at BBBSRI. The decision to refuse, suspend or terminate service is made by the Leadership Team. Wherever possible, if a participant is refused service, that service user is provided with a list of other community resources.

Reasons for refusal, suspension or termination of services:

When the Leadership Team and staff agree that a client/participant has violated the above Code of Conduct.
When a participant does not adhere or violates Program policies and procedures.
When a participant is or is perceived to be threatening, harmful, or inappropriate to fellow participants or staff.
When a participant behaves violently in any real or perceived manner.
When a participant is or is perceived to be threatening or obscene in interaction with staff or other participants.

Confidentiality Policy

In order for Big Brothers Big Sisters of Rhode Island to serve our clients in a responsible way, we must ask mentors, mentees and parents/guardians a series of questions, many of which are personal in nature. The agency respects the confidentiality of this information and, with the exception of situations listed below, shares it only among the agency professional staff. The right to confidentiality applies not only to written records, but to video, film, pictures or use of names in agency publications.

Limits of Confidentiality

Information will only be released to other individuals or organizations if an authorized "Consent To Release Information" form has been signed by the mentor or parent/guardian.
Names and photos of mentors and mentees (first name only) may be used in agency publications or promotional materials only if release form has been signed.
For purposes of program evaluation, audit, or accreditation with certain outside entities such as Big Brothers Big Sisters of America. Outside parties are required to respect confidentiality and may only use information for the purposes stated.
Information will not be provided to law enforcement officials, legal counsel or the courts without a valid and enforceable subpoena.
Rhode Island State law mandates that suspected child abuse or neglect be reported to the Department for Children, Youth & Families. All Program Staff are required to comply with mandated procedures.
If any agency staff receives information indicating that a mentor or mentee may be dangerous to himself or herself or to others, necessary steps will be taken to protect the party at risk. This may include a medical referral or a report to the local law enforcement authorities.

Short-Term Program Participation Agreement:

Please read and agree to ALL guidelines below for the entire duration of your participation at Big Brothers Big Sisters of Rhode Island. If you do not comply with this agreement, the your child will not be able to continue participation in our program.

I UNDERSTAND that this program provides short-term or one-time mentoring opportunities, and that participation is a shared responsibility between me, my child, and Big Brothers Big Sisters of Rhode Island (BBBSRI).
I UNDERSTAND that these experiences may include group sessions, workshops, or one-time events, and are not ongoing one-to-one Matches.
I UNDERSTAND that all activities will be scheduled in advance and I will be informed of dates, times, and locations.
I WILL ensure my child arrives on time and is picked up promptly at the end of each session, unless transportation has been otherwise arranged or approved by BBBSRI.
I WILL communicate directly with BBBSRI staff regarding attendance, questions, or any concerns related to participation.
I WILL notify BBBSRI as soon as possible if my child is unable to attend a scheduled session.
I WILL ensure my child is prepared to participate respectfully and appropriately in all program activities.
I WILL encourage my child to engage positively with peers, volunteers, and staff.
I UNDERSTAND that volunteers and staff are not acting as babysitters, and that programming is structured and supervised.
I UNDERSTAND that participation is voluntary, and that BBBSRI may remove a participant if behavior is unsafe, disruptive, or not aligned with program expectations.
I UNDERSTAND that social media contact between youth and volunteers is not permitted.
I UNDERSTAND that at no time can my child interact with a volunteer outside of BBBSRI's programming.
I UNDERSTAND that cell phone use during programming may be limited and is intended for emergencies only.
I AGREE to keep BBBSRI informed of any important updates regarding my child that may impact their participation.

Youth Agreement
I AGREE to participate respectfully and follow the rules during all program activities.
I AGREE to listen to staff and volunteers and treat others with respect.
I AGREE to stay with the group and follow safety guidelines at all times.
I UNDERSTAND that if I do not follow expectations, I may not be able to continue participating in the program.

I have read and understand the above information provided to me regarding Big Brothers Big Sisters' confidentiality policy. I agree to the conditions set forth.

Application Acknowledgement

I certify that all information I have provided or will provide to Big Brothers Big Sisters, including this application, is true, accurate, and complete to the best of my knowledge.

I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would affect my childs application.

I understand that information contained in my application will be verified by Big Brothers Big Sisters.

I understand to provide timely, high-quality customer service, BBBSRI utilizes AI and automated tools to assist professional staff in managing data and communications. All final determinations regarding participant eligibility, suitability, and matching are made solely by trained agency professionals.

My signature below certifies that I am granting my child to participate in Big Brothers Big Sisters of Rhode Island's mentoring programs and I have read and agree to all policies and consents listed in this application.

First Name

Last Name

Date

Contact Information