Youth Application

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BBBS of Greater Los Angeles - Candidate Questionnaire 

Please answer the following questions. This questionnaire will help us determine if our mentorship program is the best fit for your child and/or if your child is eligible to participate.

Thank you for your interest!

We apologize that we cannot continue your application at this time. Our program is not designed to meet the needs of your child. Please click HERE to find an alternative mentorship program for your child. We sincerely hope you find the help you need and again are sorry we cannot assist you and your child.

Contact Information

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. 
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.
Okay to use parent/guardian's email
If child doesn't have a phone number or email please use parent contact info.
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 Information

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










Parent/Guardian Agreement

By signing and checking the box below 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 and academic 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 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 Greater Los Angeles 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 Bigs Sister of Greater Los Angeles, 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.


Confidentiality Policy

Our mission is to provide children facing adversity with strong and enduring, professionally supported one to-one relationships that change their lives for the better, forever.
 
Big Brothers Big Sisters provides a mentoring program designed to help children whose parent/guardian has indicated a need for having a strong role model in their lives. While the program is interfaith and interracial, the desires of the child’s parent or guardian are respected in selection of the appropriate man/woman for each child. 

In determining whether an applicant may be accepted into the program, consideration will be given to personal factors of each applicant. Professional Agency personnel will determine, at their sole discretion, whether these factors may have a significant effect upon the relationship, and if revealed at a later date, could affect it adversely. 

Personal interviews are conducted to establish a profile of each applicant. All information will be kept in strictest confidence. Prior to a suggested matching, a similar profile of the Little Brother/Little Sister and his/her family will be discussed with the Big Brother/Big Sister applicant.
Access to Confidential Records 
In order for Big Brothers Big Sisters of Greater Los Angeles to provide a responsible and professional service to the community, it is necessary for volunteers, children and parents/guardians to divulge personal information about themselves and their families. The agency respects the confidentiality of child and volunteer records and, with the exception of situations listed below, shares information about children and volunteers only among the staff. The right to confidentiality applies to written records, video, film, pictures and use of a child’s or volunteer’s name in agency publications. 

In order to provide a service that is in the best interest of the children served by the program, information from outside sources, including confidential references, must be assessed along with information gained from the children, parents/guardians, or volunteers themselves.

All records are solely the property of Big Brothers Big Sisters of Greater Los Angeles. Records are not available for review by the children or volunteers. At the initial interview, children, parents/guardians, and volunteers are provided below with a copy of this statement on confidentiality along with the exceptions that define the limits of confidentiality. Each parent and volunteer shall sign a statement that he/she has read and understands the agency policy on confidentiality and agrees to program participation under the policy, in the form set forth. 

Limits of Confidentiality 
  • California state law mandates that suspected child abuse be reported to the Department of Children and Family Services. Child abuse means a physical injury that is inflicted by other than accidental means on a child by another person. Child abuse may result from either an act or a failure to act, as in the case of neglect. Child abuse also includes sexual abuse. All professional staff and volunteers shall always comply with current law and mandated procedures. 
  • If an agency worker receives information indicating that an individual may be dangerous to himself or herself, or to others, necessary steps must be taken to protect the appropriate party. This may include a medical and/or psychiatric referral or a report to the local enforcement authorities. 
  • Relevant information about a prospective volunteer and about a prospective Little and his/her family will be presented to a prospective match mate. First names only are used in this presentation. The information is shared in order for the prospective Big and/or Little and family to make the most informed choice. 
  • Identifying information regarding children and volunteers may be used in agency publications or promotional materials unless a media consent is withheld by the child or volunteer.  
  • Information will be released to other individuals or organizations only upon presentation of an authorized “consent to release information” form signed by the child’s parent/guardian or volunteer. 
  • For purposes of program evaluation, audit, or accreditation, certain outside bodies such as Big Brothers Big Sisters of America may have access to child and volunteer records. Such access will be provided only on condition that these outside organizations agree to adhere to the agency policy on confidentiality. Violations of agency confidentiality policy will be reported to the supervisor of the individual involved and appropriate disciplinary action shall be imposed. Violations of the agency’s confidentiality policy may result in termination of the employment/volunteer relationship. 
  • Members of the Board of Directors may have access to a child’s file only upon a duly authorized motion of the Board of Directors. The motion shall state who shall be authorized to review records, the specific purpose for such review and the period of time during which access shall be granted. Members shall be required to comply with the agency policies on confidentiality and may use the information only for the purposes stated by the approved action of the Board of Directors. Violations shall be reported to the Board President. A violation of the agency’s confidentiality policy by a Board Member shall constitute adequate cause for removal from office. 
  • Information shall be provided to governmental agencies, law enforcement officials, or the courts only following a valid and enforceable subpoena, court order, or in accordance with applicable law.  
  • Information shall be provided to the agency’s legal counsel in the event of litigation or potential litigation involving the agency.  
Please read, initial, and date to certify.
Initial Above
Initial Above
Initial Above


Media Consent and Release Form

I,
, certify that I am the legal parent or guardian of
, (hereafter, the “Minor Child”), and that I have full authority to execute this Consent and  Release Form.
I understand that Big Brothers Big Sisters of Greater Los Angeles (“BBBSLA”) is seeking to use my or the Minor Child’s image, likeness, name, biographical information, personal characteristics, quotations, writings, information contained in writings, and/or audio or video recordings of me or the Minor Child, whether made through BBBSLA or elsewhere (the “Released Material”) for or in BBBSLA publications or productions.

 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 BBBSLA the right to use the Released Material as BBBSLA 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 BBBSLA.

 I further grant to BBBSLA 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 BBBSLA that use the Released Materials are the property of and are owned by BBBSLA, and that I cannot authorize their use by any other party. I hereby irrevocably transfer and assign to BBBSLA 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 BBBSLA, and that BBBSLA has no liability to me for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSLA’s editing, alteration or use of the Released Materials. BBBSLA has no obligation to use the Released Materials or to exercise any rights given by this Consent and Release Form.

 I further acknowledge that, if invited and available, the Minor Child is willing and able to attend and/or speak on national or local television about the Minor Child’s involvement in the Big Brothers Big Sisters program, including to speak about the mentoring match in which the Minor Child is engaged, has engaged, or wishes to engage. I understand that BBBSLA will pay for travel and travel-related expenses for the Minor Child and one chaperone to attend such an appearance if applicable.

 I hereby release BBBSLA from all claims, demands or liabilities and related financial costs that I or the Minor Child may now or hereafter have arising in connection with BBBSLA’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.


COVID-19 | Assumption of Risk, Hold Harmless and Liability Release

In connection with my participation in, and in connection with my engagement with, Big Brothers Big Sisters Of Greater Los Angeles (“Organization”) and for other good and valuable consideration, I hereby acknowledge and agree the following as part of this Assumption of Risk, Hold Harmless and Liability Release (the “Release”) 

I acknowledge, understand, and am aware that portions of the Organizations activities are intended to take place in regions potentially affected by COVID-19 (also known as the Coronavirus) and other diseases, illnesses and hazards (collectively, “Affected Area”), and that I may be in proximity to and/or interacting with individuals who may be sick, who may or may not be exhibiting symptoms or who may be infected by COVID-19 or who may be otherwise contagious. I am aware that the Centers for Disease Control and Prevention (“CDC”), in addition to other local, state and federal health and government agencies have issued numerous alerts, warnings, advisories, restrictions, directives and in some cases orders regarding the transmission and potential effects of COVID-19 and I fully acknowledge and accept the risks involved in voluntarily being in the Affected Area. I hereby acknowledge and agree that I am voluntarily deciding to remain in the Affected Area and that my decision to do so is mine and mine alone, which I arrived at after careful thought and consideration, and which has not been influenced by Organization, or any representatives, employees, agents or affiliates thereof, and further, such decision is not required as a condition of my future services, activities, or involvement in connection with the Organization or otherwise. I further acknowledge that my election to remain in the Affected Area may significantly increase my risk of contracting COVID-19. By electing to remain in the Affected Area, I acknowledge and agree that I am voluntarily potentially exposing myself to various hazards, including but not limited to, illness, injury, infection, and/or death. I acknowledge and agree that it is my responsibility to take appropriate health and safety precautions. I freely and knowingly accept and assume any and all risks of being in the Affected Area as well as any risks not mentioned herein that are associated with my engagement in and in connection with the Organization. 

I represent and warrant that I am in good physical health, that I do not have any of the conditions that the CDC has categorized as “high risk” in the event I contract Covid-19 (including, without limitation, preexisting, underlying or chronic health conditions or previous medical concerns or diagnosis), and that I am physically able and mentally capable of engaging in the Organization’s activities in the Affected Area. In the event I begin to exhibit symptoms of Covid-19, or I otherwise feel sick, I acknowledge and agree that I will immediately notify the Organization and discontinue my engagement hereunder. Additionally, I will immediately notify Organization if I have been exposed to, or am exposed to, someone who has tested positive for Covid-19. 

To the fullest extent permitted by law, I hereby expressly release, indemnify, discharge and hold harmless Organization, and its licensees and assigns, and each of their respective parent, subsidiary, affiliated and related companies, and their respective officers, directors, employees, representatives, licensees, assigns and designees, from and against any and all liability, claims, demands and causes of action of any kind, including without limitation, claims for personal injury, disability, death, property damage and/or other loss of any sort suffered by me in connection with my engagement by Organization, or any other adverse consequences or outcomes that may result from my engaging in services in connection with the Organization and/or being in the Affected Area. 

This Release shall be deemed to be entered into in the State of California and shall be governed by and interpreted in accordance with the internal laws of the State of California. If any controversy or claim arising out of or relating to this Release, or the breach of any term hereof, cannot be settled through direct discussions, the parties agree to endeavor first to settle the controversy or claim by mediation conducted in Los Angeles County, California and administered by JAMS under its Commercial Mediation Rules. If a controversy or claim is not otherwise resolved through direct discussions or mediation, it shall be resolved by arbitration conducted in Los Angeles County, California, and administered by JAMS in accordance with the commercial arbitration rules of JAMS (the "JAMS Rules"). The JAMS Rules for selection of an arbitrator shall be followed, except that the arbitrator shall be an experienced arbitrator licensed to practice law in California. This Release is in addition to any similar assumption of risk or releases that I may have previously entered into with Organization. 

This Release shall in no way be deemed to limit such previous release (if any) or its applicable provisions, and I agree that the waivers, releases, assumptions of risk and indemnities in any such previous release or agreement shall additionally expressly apply to my engagement with the Organization and/or my being in the Affected Area hereunder. In the event of a conflict between the any previous release or agreement and this Release, the terms of this Release shall govern solely to the extent necessary to resolve such conflict.