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BBBSChi Site Based Youth Application

Site Based Mentoring Program Overview

Dear Parent/Guardian:

Your child has the opportunity to participate in the Big Brothers Big Sisters of Metropolitan Chicago (BBBSChi) Site Based Mentoring Program. In this free program, your child is matched 1:1 with an adult, Volunteer Mentor (Big). They will meet* with other matches, and there will be BBBSChi staff to supervise and facilitate all of the program sessions. The goal of the program is to provide positive modeling and interaction between adults and children, character building, and relationship development that leads to school and lifetime success.

The BBBSChi Site Based Mentoring Program process:

Youth can be referred by school/site staff or their Parent/Guardian.
All youth for which an application has been submitted will be interviewed by BBBSChi staff. The Agency reserves the right to accept or deny participant’s admission into the program.
Upon acceptance and identifying a match for the child, Parent/Guardian will be notified of their child's match and official start date.
The child will spend about an hour and a half with their Volunteer Mentor in a supervised setting participating in a variety of activities, including building skills for academic and social success, teambuilding, working on schoolwork, playing games, creating arts and crafts, and talking.
To provide a holistic mentoring experience, BBBSChi will collect the child’s personal, social, and academic information from his/her school or youth serving organization each quarter.
The child and their Big are NOT allowed to see one another outside of the Site Based program, unless it a BBBSChi sponsored field trip or event and additional permission or supervision is requested. At no time should your child’s mentor be transporting your child or meeting your child outside of the BBBSChi program. With your permission, your child is allowed to have phone/email contact with their mentor to enhance their match relationship development.

Thank you.

--BBBSChi Staff

Site Based Program Selection

For which site location/program are you applying?

Refer to the program name in the email from your recruiter or other BBBS Staff.

Account ID

Site Location

Populated upon program site selection

IMPORTANT: Please be sure to select the correct program. If your company or college/university has a partnership with BBBS, please ensure you are choosing your respective program. If you are unsure, please contact our recruitment staff.

Referral Detail

Which BBBS staff referred you?

Type 'BBBS Board/Staff'...then select the staff name who referred you.

Referral Detail ID

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

Please note that all information requested in this application will be kept confidential and will not be released without your permission.

First Name

Middle Name

Last Name

Preferred Name

Birthdate

mm/dd/yyyy

Personal Pronouns

(Write In.) Personal Pronouns

Gender Identity

(Write in.) Gender Identity

Sexual Orientation

(Write in.) Sexual Orientation

Race/Ethnicity

Press & hold CTRL to select multiple options.

Current School Name

High School Graduation Year

This is the year the youth will graduate high school.

Is the child a CPS student?

YesNo

Does the youth have their own cell phone?

YesNo

Youth's CPS email address

Youth's Phone #

Youth Email Address

Enter Parent/Guardian email if child has no email.

At what time does the child end their school day? Does the child participate in any other activities/programs after their school day? If yes, please describe and include the time and schedule of these other activities

Does the child have the ability to actively participate in virtual programming (i.e. access to internet, a laptop, etc.) or will the child require additional support/resources? Please describe in detail. BBBSChi may be able to provide resources and other support for the child and their family.

Youth Health Information

Does the youth have any allergies?

YesNo

Allergies or Asthma Description (Please describe when and for how long child has had allergies and any other information staff may need to know for your child's safety.)

Diagnosis & Trauma

Does the youth have any chronic illnesses, mental health or developmental diagnoses or any exposure to trauma?

YesNo

Press & hold CTRL to select multiple options.

Developmental Diagnosis

Mental Health

Chronic Illnesses

Youth's Exposure to Trauma

Is the youth taking any medications?

YesNo

Medications Description (Please include the name, dosage and any other important information staff should know for your child's safety, including if your child is able to administer their medication)

Other Medical Information

Enter N/A if none

System Involvement

The questions below help us to inform programming, partnerships, and how we individually serve each youth. We do not pre-judge youth or families due to their answers; responses provide us with the clearest picture on how to meet the individual youth's needs.

Has the youth ever been involved with the police or juvenile justice system?

What was their involvement?

Does the youth have a parent/guardian who is currently incarcerated?

YesNoPrefer not to answer

Were you referred by The Prison Fellowship/Angel Tree?

YesNo

(Optional) Name of Incarcerated Parent

(Optional) Name of Institution

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Home Phone

Mobile Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Best Day(s) to Call (Select all that apply):

Press & hold CTRL to select multiple options.

Personal Email:

Alternate Email:

Leave blank if no alt. email. Do NOT put N/A

Work Email:

Leave blank if no work email.

Preferred Email

Contact Preference

Employer

Type N/A if unemployed

Days/Hours of Employment

Language Preference

Parent/Guardian Relationship to Youth

Family Information

Describe your child’s home environment and family structure.

Mailing Address

Mailing Street

Mailing City

Mailing State

Mailing Zip

Mailing County

Check here if your mailing address is different from your home address:

Does the youth reside in the city of Chicago? ?

YesNo

Does the youth reside in CHA (Chicago Housing Authority) housing or does the family receive a Housing Choice Voucher?

YesNo

Home Address

Street Address

City

State

Zip Code

County

Youth Living Situation

Living Situation Description

Is there a person who shares custody of this youth?

YesNo

Custody is shared with:

Relationship to Youth

Does the youth have a parent/guardian who is serving or served in the military?

Does the youth have a parent/guardian that is currently deployed?

YesNo

Annual Household Income

Does your family receive income assistance?

YesNo

Is the youth eligible to receive free/reduced lunch?

YesNo

Existing Household Members

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

Name:	Relationship:
App record ID	Contact record ID

Emergency Contact

This individual will be contacted in an emergency situation only when the youth's Big or BBBS staff are not able to get in touch with you, the parent/guardian.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Relationship to Youth

Youth Needs & Match Preferences

What are the youth's strengths? (i.e. School performance, classroom behavior, peer relationships, self-esteem, etc.)

What are some areas in which you would like to see growth in the youth? (i.e School performance, classroom behavior, peer relationships, self-esteem, etc.)

In what other areas have you noticed the youth needs guidance? (Check all that apply.)

Organization	Focus	Motivation
Respecting Boundaries	Anger Management	Financial Literacy/Planning
Time Management	Respecting Authority	Social Skills
Participating in Group Activities	Independent Thinking	Communication
Decision Making	Understanding the Effects of Choices	Self-Expression
Consideration for Others	Confidence	Self-Esteem
Meeting New People	Trying New Things	Building Relationships

Do you have any special preferences regarding the adult, Volunteer mentor who may be matched with the youth? (i.e. race, religion, sexual orientation, gender identity, age, occupation)

Media Consent

BBBSChi Media Consent:

I, as the legal parent or guardian of my child for whom I have completed this application, irrevocably consent for myself and Minor Child to any and all uses and displays of my or Minor Child’s name, image, likeness, appearance, and basic biographical information in, on, or in connection with any advertising, publicity, marketing, or printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America, [BBBSA affiliate], and any of their affiliates, successors, partners, sponsors, donors, and any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type 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.

I consent to the above statement.I do NOT consent to the above statement.

Volunteer (Bigs) Media Consent:

My child’s assigned Big Brother/Big Sister may post photographs and share information about the match on social networking websites. I understand Bigs may be allowed to post my child’s first name but no other identifying information (i.e. last name, home address, school the child attends, etc.)

I consent to the above statement.I do NOT consent to the above statement.

Expectations & Guidelines for Parents/Guardians

I understand that:

BBBSChi is not obligated to accept my child for the Big Brothers Big Sisters program. Furthermore, BBBSChi reserves the right to withhold the reasons for non-acceptance. 
All information obtained regarding my child will be held in confidence by BBBSChi. I will only have access to my application. All other information concerning my child, including but not limited to information derived from the enrollment process, interviews or otherwise, will be the sole property of BBBSChi. Information about my child, as it pertains to the matching process, may be shared with teachers, counselors, youth partner staff, BBBSChi staff, and volunteer mentors. BBBSChi will not release to outside sources, unless required by law, information from my child’s enrollment file, without my prior written consent.
My child is expected to attend, at minimum, at least 80% of all scheduled program sessions. If my child is unable to attend a program session, either I or my child must inform BBBSChi staff. Failure to comply with these attendance requirements may result in the closure of my child's match and my child not being able to participate in the program.
My child is not allowed to meet 1:1 in-person with their mentor, outside of the supervised program sessions/BBBSChi supervised field trips/events.  
My child is allowed to game on all video game platforms with their mentor. The timing of gaming between Big and Little should be coordinated with the parent/guardian and BBBSChi stafff. Ensure video game content is age appropriate. Social networking between mentors and my child is strictly prohibited.
BBBSChi and my child's mentor may communicate with my child via phone, email, text, BBBS' TheApp and other video platforms. Video chatting should only occur in common areas of the home and when parents/guardians are present.
On-going match support will occur with my child in order to monitor the match and provide support and resources.
Communication is vital to the success of the mentoring relationship. My child or I may be contacted by BBBSChi staff to have a conversation about my child's match relationship and experience in the program. Phone calls and emails received from BBBSChi staff must be returned/replied to within 48 hours.
My child’s mentor can attend up to 3 of my child’s out of program, public events per year if I give written/verbal permission to BBBSChi staff for each event. My child’s mentor may never transport my child at any time.
My child will complete program questionnaires as well as talk to BBBSChi staff and BBBSChi volunteer mentors about topics including, but not limited to, school, home life, personal interests, and personal safety.
My child will participate in assessments and evaluations in regards to the BBBSChi program. 
I may be invited to attend program sessions or Parent/Guardian meetings throughout the year, which I will make every effort to attend.
My child may ride a school bus for in-person program sessions and/or to participate in BBBSChi group field trips.
The School District, School, Institution or Youth Serving Organization my child attends can release the following information to BBBSChi quarterly or as requested, including such information as grade point average, photocopies of report cards, school attendance, grade advancement, student ID#, graduation information and noted social and academic information (i.e. relevant behavior reports and/or counselor/social worker feedback). 
BBBSChi staff will hold my child’s disclosures related to the child’s gender identity and/or sexual orientation confidential if my child does not want that information shared with me. Agency staff will encourage my child to find a safe and supported way to share this information with me when the child is ready to do so.
Keeping my child safe is a priority for BBBSChi and I understand that I play a role in this, including asking my child about their mentor and the activities they participate in, informing the staff if I have any concerns regarding my child’s relationship with their mentor, and monitoring that all rules are being followed.
BBBSChi staff are mandated by the Illinois Abused and Neglected Child Reporting Act to report any concerns, suspicions, and/or incidents of abuse or neglect.

I have read the above Expectations & Guidelines for Parents/Guardians, which define the ground rules and my responsibilities as the parent/guardian for the safety of my child. I agree to abide by them as long as my child is in the program, and I understand that BBBSChi has the right to close my child's match at any time.

BBBSChi COVID-19 WAIVER

In-Person Session Guidelines

Big Brothers Big Sisters of Metropolitan Chicago will allow matches in both Illinois and Indiana to take part in in-person sessions upon receipt of a signed waiver from both Big and Parent. Meeting in-person outside of agency organized events continues to be against the Site Based program rules.

In-person sessions are at the discretion of each match and its participants. Your child may choose to

maintain a virtual relationship with their match and begin in-person group sessions once all match parties are comfortable.

If any party in the match relationship is at heightened risk for the Coronavirus, your child should not meet in person at this time. This may also include family members, partners, or roommates. Heightened risk factors include age, respiratory illness, diabetes, immune system suppression, among many others.

Communicating about COVID-19 & Risk Factors in your Match

Each person in the match needs to assess their health directly before each session: Is your child feeling achy? Fever or chills? Fatigued? Cough or tightness in chest? Before each session, all parties should do this self-evaluation and discuss with each other to determine if your child should attend the group session. If not, opt for a virtual visit instead.
Share with Agency staff if your child or someone in your home has been exposed to someone with COVID-19 or had exposure to a large number of people.

We need to be open and honest with each other so we can protect one another and work together to make the best informed decision about a program session.

BBBSChi staff will be clear on planned activities when communicating with match parties, and all match parties, including parents/guardians, should communicate any restrictions they require and give specific approval to the session.
When together in-person your child will be reminded about rules for the day.

Protocol for In-Person Group Sessions

Match parties are not required wear a mask during sessions. They can wear a mask if they prefer.
Wash and sanitize hands frequently.

BBBSChi COVID-19 Group Session Waiver

I have read the agency’s COVID-19 Match Contact Guidelines and I agree to adhere to all items listed to the best of my ability. I understand my child is not obligated to attend the group session and have in-person contact with their match, and that they are expected to continue virtual contact if not having in-person contact.

I will make decisions based on what is best for the safety, health, and wellness of each person in my child's match and our families. I will discuss these considerations in depth with each person in my child's match and ensure we are all in agreement before proceeding.

If I have questions or concerns about how best to do this, or about any of the guidelines listed here or any other concerns related to the BBBS program, I will contact my child's Program Facilitator.

I will not hold Big Brothers Big Sisters of Metropolitan Chicago (BBBSChi) or its directors, officers or employees, responsible if my child or one of his/her family members contracts COVID-19 or any illness. I will not hold Big Brothers Big Sisters of Metropolitan Chicago (BBBSChi) responsible for any damages that may result from contracting an illness, including all liability, claims or demands arising from any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law. This release is binding on heirs, executors, administrators, assigns, agents, attorneys and representatives.

I understand and agree to the above statement.

Parent/Guardian Agreement & Permission Form

I agree to let my child participate in the BBBSChi Program. I understand that certain risks and dangers may exist in my child’s/ward’s attendance and participation in this Program is conditioned upon my agreement to release any claims of liability, including, but not limited to, any claims for property loss or personal injury to my child/ward.  Therefore, in exchange for my child/ward attending and participating in the Program, I hereby voluntarily release BBBSChi , its board, officers, staff, employees and volunteers from all claims which I or my child/ward may have for liability or legal responsibility for any damage or loss of any kind, including, without limitation, claims for personal injury, property damage or loss, and economic loss occurring during or resulting from my child’s attendance and/or participation and/or travel to or from their school/site or field trip/program destinations which is caused by negligence, breach of contract, strict liability, or otherwise.

I give permission for (1) my child to participate in the Big Brothers Big Sisters Program; (2) the school my child attends, or any other entity holding academic or other information about my child, to provide social, academic, and other information/ records about my child to BBBSChi that are useful or necessary in assessing, planning or implementing educational interventions by BBBS staff (e.g. report cards, phone numbers, STAAR/ EOC exams/ standardized test scores, attendance records, behavior reports/ referrals, counselor and teacher reports, special education referrals and tests, free/reduced lunch status, etc.); (3) BBBSChi to disclose information to school representatives for the purpose of assessing, planning or implementing educational interventions (e.g. identifying information such as name, school ID, and social security number); (4) my child to complete a questionnaire containing questions about school, home life, and personal interests; (5) my child to speak with a BBBSChi staff person about personal safety; (6) my child to communicate with their volunteer and BBBS in person, over the phone, by text, email, mail, BBBS’ TheApp or using other virtual technology/platforms; (7) my child to be transported by bus for any in-person program sessions or field trips.

I accept and agree to the terms and conditions.

Click 'SUBMIT' below to submit your application.

NOTE: A Parent or Guardian must digitally sign this application!

After you have clicked 'SUBMIT,' you will be prompted to enter your name, email and digitally sign this application. An automated email will be sent to you, confirming your application has been submitted and will also include a link for you to confirm your digital signature.

You MUST click the link in your email in order to complete the application process. After confirming your signature, a BBBSChi staff member will be in contact with you to discuss next steps in your child's enrollment process.

Thank you!

Contact Information