BBBSCR 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

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. Big Brothers Big Sisters of the Capital Region, Inc., a non-profit Pennsylvania corporation, to make available the services of BIG BROTHERS BIG SISTERS to my child, and if possible, assign him/her to a screened volunteer.  
  2. I give my consent for my child and myself to participate in all assessment and evaluation services by a Big Brothers Big Sisters or school staff person; to cooperate and assist in all planning activities, and to receive all services for my child as deemed necessary by Big Brothers Big Sisters of the Capital Region.
  3. I agree to participate in and allow my child to participate in required monthly match support.  Furthermore, I give my consent for my child and I to participate in all outcome-based evaluations and surveys.  I consent to my child completing a questionnaire and interview containing questions about school, home life, and personal interests and safety.
  4. I agree to have my child talk with a Big Brothers Big Sisters staff person about personal safety. 
  5. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. 
  6. I give my consent for my child to be transported by the volunteer matched with my child and/or Big Brothers Big Sisters of the Capital Region staff.
  7. I authorize the school to provide information about my child that may be relevant to his/her participation in the Mentor Program.
  8. I hereby knowingly release and hold harmless Big Brothers Big Sisters of the Capital Region and their nominees, assignees, and designees from any and all liability for any damages incurred due to any injuries sustained by my child or myself as a result of my child’s participation in any Agency sponsored activity or in being transported thereto.

I give my permission for my child to participate in the Big Brothers Big Sisters program. I understand that the BBBS agency is not obligated to match my child with a volunteer. I also understand that as part of the enrollment process I may be asked to provide additional personal information. If my child is matched with a Big Brother or Big Sister I agree to support my child’s match and to immediately report any concerns I might have to the Big Brothers Big Sisters staff. By clicking the box, I am acknowledging the information I have listed is accurate to the best of my knowledge.

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 Capital Region 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. 

 

Confidentiality Policy

Big Brothers Big Sisters of the Capital Region respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among professional agency staff. All records are considered property of the agency and not the agency workers or clients and volunteers themselves. Records are not available for review by clients or volunteers. 1. Information will be released to other individuals or non-BBBS organizations only with client or volunteer written consent. 2. Identifying information regarding clients and volunteers may be used in agency publication or promotional materials unless the client or volunteer request otherwise. 3. For purposes of program evaluation, audit, or accreditation, and with the 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. 4. Members of the Board of Directors or evaluators appointed by the Board have access to client and volunteer records only upon authorization of the Board. 5. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena. 6. Information shall be provided to the agency legal counsel in the event of litigation or potential litigation involving the agency. 7. State law mandates that suspected child abuse be reported to the appropriate authorities. 8. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself/herself or others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or a report to local law enforcement officials. 9. At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. The information shared may include such items as: age, sex, race, religion, interests, hobbies, marital status, family status, sexual orientation, living situation, etc.

Medical Release

I hereby give permission for my child to receive emergency medical treatment.  I understand that in case of accidental injury or sickness while my child is with the volunteer Big Brother/Big Sister it may be necessary to seek and obtain medical attention at a physician’s office or at a hospital for my child.  I understand that I will be notified as soon as possible but until my arrival, the volunteer Big Brother/Big Sister bearing this notice can make all decisions for the care of my child.  I understand that I will be responsible for the payment of any resultant expenses.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

1. Your child’s Big Brother or Sister is NOT: a taxicab service, Santa Claus, or a babysitter. Please do not treat them as such. 2. Please do not discuss your child with the volunteer in the presence of the child. If you think there is something he or she should know, call the volunteer when your child is not present. 3. Try to help your child be considerate of the volunteer (i.e. remembering birthdays, making occasional phone calls, etc.). 4. If there is something about the relationship that concerns you, contact your Match Support Specialist immediately. 5. Once in a while, try to let the volunteer know, that his or her efforts are appreciated. 6. Remember, the relationship that exists is between your child and the volunteer. Do not ask that siblings, relatives, friends or you be included on outings. 7. Forgive minor mistakes in judgment. The Big Brother or Sister is not a trained professional, nor is he or she perfect. You will probably disagree with the volunteer sometimes. 8. You should not deprive the child of the weekly visit with the Big Brother or Sister as a means of discipline. 9. The Big Brother or Sister will be telling you when he or she will be returning your child. Please make a point of being home. 10. Be flexible. Remember the volunteer has a busy schedule. 11. Give it time. This relationship needs time to develop—at least three months—so do not judge too quickly. 12. Your child’s Big Brother or Sister is a person too. Get to know him or her at least to the degree that you feel comfortable with him or her. 13. Please return calls promptly to your Match Support for your monthly/quarterly updates. 14. No relationship can be terminated without consulting the BBBS office. 15. When meetings are scheduled, every attempt must be made to attend them. 16. In signing these guidelines, I am also granting permission for the Professional Staff of BBBS to meet or observe my child in school if necessary. 17. Your child may only visit the mentor's home after three (3) months and with parent, BBBSCR and mentor approval. 18. Your child may not visit the mentor overnight.

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 BBBSCR on BBBSCR and NATIONAL websites, including capbigs.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. BBBSCR COPPA statement is incorporated in the website's Privacy Policy. BBBSCR 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 info@capbigs.org.
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