HSLP Youth Application

Thank you for your interest

Thank you for your interest in the Big Brothers Big Sisters High School Leadership Program being run through your child's school within the Schenectady City School District. Please complete this application form to enroll your elementary school student as a mentee with Big Brothers Big Sisters of the Capital Region. Programming will begin in October.

Learn more about our program here: Frequently Asked Questions

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 of parent, 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

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Mobile Phone

Home Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Work Email

Alternate Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

Family Information

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

Annual Household Income

Is your child eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

Is parent/guardian receiving assistance with housing (i.e. Section 8, residence in public-housing, etc.)?

YesNo

Do you anticipate any significant life changes over the next year, or have you had any in the past year?

YesNo

Life Changes Description

Existing Household Members

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

Name:	Relationship:
App record ID	contact record ID

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Confidentiality Policy

https://docs.google.com/document/d/1EIaztjvXn2DNzX-9YDO6mWqC6lb5ON0bSVxyn2Wg0yw/edit

I have read and understand the above information provided to me regarding Big Brothers Big Sisters Confidentiality Policy. I agree by the conditions set forth.

I consent to use images and consent to use my name and/or my minor child's name in promotional materials for Big Brothers Big Sisters of the Capital RegionI do not consent

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

By signing below, I give permission:

For my child to participate in the Big Brothers Big Sisters Program;
For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);
To have my child partcipate in an enrollment interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests;
To have my child talk with a Big Brothers Big Sisters staff person about personal safety;

I understand that the program is not obligated to match my child with a mentor and that as part of the enrollment process I may be asked to provide additional information. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the mentor who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information shared in my child’s in-take interview).

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 do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating 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 his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable.

If my child is matched with a mentor, 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 twice per semester, and immediately report any concerns I might have to the school or Big Brothers Big Sisters staff. I understand that Big Brothers Big Sisters staff is available to me at any time and I can reach out with any questions or for referrals.

I have read the above youth safety guidelines and ground rules which define my responsibilities as the parent/guardian of a mentee. I agree to abide by them as long as my child is in the program and I understand that BBBS has the right to close my child’s match at any time.

Big Brothers Big Sisters of the Capital Region partners with the Healthy Alliance Network to make connections for the youth/families in our programs that meet their social needs – food and housing insecurity, difficulty navigating benefits, shortage of clothing and household goods (and so much more). This enables BBBSCR to link you to providers of all kinds (from regional hospitals to local food pantries and everyone in between) across the Capital Region.

Yes, please share my family’s personal information (full household contact information and demographic data) with the Healthy Alliance Network so that I may receive referrals should I need them now or in the future.No, please do not share my family’s personal information (full household contact information and demographic data) with the Healthy Alliance Network at this time. Should my family need referral services in the future, we can opt-in at that time.

Gender	Personal Pronouns
How does your child identify?	What pronouns does your child use?
School	Graduation Year This is the year the youth will graduate.