BBBS MI Capital Region 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

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For notifications



Youth Information





Enter a date in the following format: mm/dd/yyyy





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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


Community-Based Program- Bigs and Littles get together 2-4 times a month for a few hours each time at a time that is convenient for both the Big and the Little. The match can do activities they both enjoy like going to the park, making dinner together, play games, etc.

Site-Based Program- BBBSMCR partners with Everett High School and the Waverly School District and the Big meets with their Little at their school. This type of match meets weekly on the same day during the lunch and recess time. This type of match can enjoy spending time playing games, reading, working on homework, etc. Site based matches are only permitted to meet at the site location and may not meet in the community.





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.

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 Michigan 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. 
 

Please note BBBSMCR does not use any individuals last name.

Confidentiality Policy

SAFEKEEPING OF CONFIDENTIAL RECORDS

 

The Executive Director is considered the custodian of confidential records.  It is his/her responsibility to supervise the management of confidential information in order to ensure safekeeping, accuracy, compliance with Board policy and accountability.  He/she shall assure that there are appropriate procedures that implement the confidentiality policy. 

 

ACCESS TO CONFIDENTIAL CLIENT AND VOLUNTEER RECORDS

 

In order for Big Brothers Big Sisters Michigan Capital Region (BBBSMCR) to provide a responsible and professional service to clients it is necessary for volunteers, clients, and parents/guardians of clients to be asked to divulge extensive personal information about themselves and their families. The agency respects the confidentiality of client and volunteer records and, with the exception of the situations below, shares information about clients and volunteers only among agency professional staff.  (Note: these files are handled by staff, both paid and volunteer.)  The right to confidentiality applies not only to electronic and hard copy records, but also to film, photos, and the use of client or volunteer’s name in agency publications.

 

All records, electronic and hard copy are considered the property of the agency and not the agency staff, clients or volunteers themselves.  Files are not to be removed from the agency without prior consent from Executive Director or Program Director.  Upon separation from the agency, BBBSMCR will immediately change passwords and deny access to agency files to terminated employees.

 

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 clients or volunteers themselves.  Records are, therefore, not available for review by the clients or volunteers. 

 

Limits of Confidentiality

Information from client or volunteer records may be shared with the individuals or organizations specified below and under the following conditions:

 

1.    Information will be released to other individuals or organizations only upon presentation of an authorized “consent to release information” form appropriately signed by the client or volunteer.

2.    Identifying information (including photos, videos, etc.) regarding clients and volunteers may be used in agency publications or promotional materials if the client or volunteer has given permission.

3.    For purposes of program evaluation, audit or accreditation, and with the prior approval of the Board of Directors, certain outside bodies may need access to client and volunteer records.  These outside organizations shall be required to respect the agency policy on confidentiality.  Outside parties shall be required to use information only for the purposes(s) stated in the approved action of the Board of Directors.  Known violations of the agency’s confidentiality policy will be reported to the supervisor of the individual involved and appropriate disciplinary action shall be requested.

4.    Members of the Board of Directors have access to client files only upon authorization by formal motion of the Board of Directors.  The motion shall identify the person(s) to be authorized to review such 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 policy on confidentiality and use the information only for purposes stated by the approved action of the Board of Directors.  Known 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.

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 an agency’s legal counsel in the event of litigation or potential litigation involving the agency.  Such information is considered privileged information and its confidentiality is protected by law.

7.    State law mandates that suspected child abuse will be reported to the appropriate authorities.  All workers are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.

8.    If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps shall be taken to protect the appropriate party.  This may include a medical referral or a report to the local law enforcement authorities.

9.    At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties.  However, the identity of the prospective match mate shall not be revealed at this stage.  Names are shared with match mates only after the involved parties agree to the match.  Information that may be shared include:

Volunteer:  age, gender, race, employment, education, interests, personality “type”, experience with children, living situation, family history, habits/living patterns, motivation for volunteering.

Client:  age, gender, race, economic status, hobbies, living situation, school situation, personality “type”, family situation and health.

The client and volunteer shall have the right to review and approve the specific information before it is presented to the potential match mate, the individual to whom the information is provided shall agree in writing not to share the information with any other person.



Parent/Guardian Agreement

By checking the box below and providing my signature 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 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 Michigan Capital Region 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 Michigan Capital Region, 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.