By accepting The Terms and Conditions, 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 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 Lubbock 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 Lubbock, 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.

I authorize the BBBS volunteer assigned to my child(ren) or any director or staff member of BBBS to obtain necessary medical and/or surgical treatment in the case of illness, accident or any emergency situation that may arise for my child(ren) listed below.  These medical services are to be performed by the Hospital and/or Physician listed below or in his/her absence, any licensed medical doctor.  I further state that I will not hold BBBS volunteer or any director or staff member liable in the case of illness, accident or emergency situation.

I, the legal parent or guardian of the child(ren) listed below, (“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 Lubbock, 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.

I have read this Consent and Release Form completely. I fully understand what it means, and I agree to its terms. I have not been offered any additional consideration or enticement, nor have I been coerced to sign this document. I am voluntarily signing it for the purposes and considerations described.

Big Brothers Big Sisters of Lubbock incorporates photographs, slides, videotapes, digital video disks, films, television/radio tapings and or pictures for the sole purpose of promoting the agency in the media such as, but not limited to, newspaper articles, BBBS of Lubbock website, Facebook and our poster campaign. 

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 Lubbock on Big Brothers Big Sisters of Lubbock and NATIONAL websites, including bbbslubbock.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of Lubbock COPPA statement is incorporated in the website Privacy Policy here: https://www.bbbs.org/legal-notices/privacy-policy/ .  Big Brothers Big Sisters of Lubbock 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 and activities associated with the agency.

By completing this form and submitting it to Big Brothers Big Sisters of Lubbock, you certify that you consent to the collection, use and/or disclosure of your child’s personal information as described in Big Brother Big Sisters of Lubbock’s privacy policy.

 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 write down your revocation of consent and scan and email the signed form to Staff@bbbslubbock.org, or mail it to us at 3416 Knoxville Avenue, Lubbock, Texas 79413 

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

I have been informed about the content, requirements and expectations of Big Brothers Big Sisters.  I have received a copy of the Parent/Caregiver Orientation Guide which includes agency guidelines and ground rules.  I agree to abide by the policy guidelines and ground rules as a condition of my child’s involvement with Big Brothers Big Sisters.  I understand that a violation of guidelines and ground rules could result in my child being removed from the program.

The safety of clients and volunteers of Big Brothers Big Sisters are a top priority of this agency.

I understand that it is the policy of Big Brothers Big sisters that my child(ren) is (are) only allowed to go on outings/activities with their assigned Big Brother/Big Sister through Big Brothers Big Sisters.  I understand that no siblings, other family members or friends of my child are allowed on these outings/activities.  

I understand that it is a requirement for the Parent/Guardian to complete the Big Brothers Big Sisters Parent Safety Training, before my child is eligible to be matched with a volunteer.

I understand that any breach of this agreement could result in the termination of my child(ren)’s participation with Big Brothers Big Sisters.

I understand that if I have questions, at any time, regarding my child’s involvement with Big Brothers Big Sisters, I will consult with a Big Brothers Big Sisters staff member.