Youth Application

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

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 the youth eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

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

How did you hear about Big Brothers Big Sisters?

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

Big Brothers Big Sisters of the Tennessee Valley respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.

All records are considered the property of the agency and not the agency workers or clients or volunteers themselves. Records are not available for review by the clients or volunteers.

Information will be released to other individuals or non-BBBS organizations only with the client or volunteer's written consent.

Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteers request otherwise.

For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies such as Big Brothers Big Sisters of America may have access to client and volunteer records.

Members of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors.

Information will be provided to law enforcement authorities only upon the issuance of a valid and enforceable subpoena. However, general verbal information i.e., your affiliation with our organization and information that may be found, for instance, in BBBS publications may be given upon request of law enforcement authorities.

Information shall be provided to an agency's legal counsel in the event of litigation or potential litigation involving the agency.

State law mandates that suspected child abuse be reported to the appropriate authorities.

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

At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. The information about the volunteer may include such items as: age, sex, race, religion, interests, hobbies, marriage, family status, sexual orientation, living situation, etc. Information about the child may include such items as age, sex, race, religion, interests, hobbies, family situation, etc.

I have read and understand the above information provided to me regarding Big Brothers Big Sisters' confidentiality policy. I agree to the conditions set forth.

Guidelines and Grounds Rules for Parents/Guardians

Parent/Guardian

Be an active partner. Working together, parents or care givers, volunteers, and BBBS staff members plan activities and opportunities that can have a powerful and positive impact on your child. Here’s what you can expect to participate in as a partner in this match.

Talk with Match Support monthly. We will contact you monthly to get your point of view about the match, observations and questions. This monthly contact is required - it allows us to provide support, and offer ideas if problems arise. Note that for safety purposes, we will suspend or terminate any match where consistent conversation is not occurring.

Along with your child, participate in scheduled assessments and other requests. Big Brothers Big Sisters uses assessment date to recommend match direction, identify resources you may need, to evaluate the effectiveness of the program and of course, to ensure safety.

Know about each activity and give your approval in advance. When your child returns home from an activity with their Big, it's very important that you talk openly with them about the activity. We'll talk with you about your observations and conversation during our monthly conversations.

Call us! If you need help locating resources, are moving, have a joy to share, have safety concerns or need to talk about the match, call your Match Support Specialist.

Respect boundaries. We educate volunteers, families and Littles' about the importance of focusing on what this match is and what it isn’t. For example, we ask all parents to remember that the Big is a volunteer and should not be asked to perform any services for the family, buy clothes or supplies, be asked to take siblings on outings, bring the child home to an empty house, and so on. We’ll look more at volunteer roles and responsibilities further on in this guide.

Follow all policies, procedures and ground-rules. Without exception, it is critical to safety and healthy relationship development that you adhere to our rules, as do our volunteers. We will discuss these during your training.

Support your child's mentoring relationship. The time your child spend with his or her Big can be an invaluable experience so sticking to scheduled times, getting to know the Big, talking with your child about the experience and promoting the activities and events offered by the agency are great ways to partner.

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

Authorization for Release of Information

I give my consent to allow any counseling, therapy, or medical service my child has, is, or will be seeking to release confidential information to Big Brothers Big Sisters of the Tennessee Valley for my child.

The purpose of this information exchange is to solicit service for my child from Big Brothers Big Sisters of the Tennessee Valley (BBBSTV). Further, I give consent to continued authorization to discuss my child’s situation as it relates to receiving services through BBBSTV. If my child receives such services, the information exchange will be to keep BBBSTV apprised of my child’s status and development within the community as well as other issues which may affect Big Brothers Big Sisters of North Alabama’s ability to provide their services to my child. BBBSTV staff and/or volunteer agree to maintain the confidentiality of any information released.

I understand the following information may be released: diagnosis/ prognosis, medications, family relationships, and behavior in the community, from my child’s mental or medical professional.

This authorization shall expire upon written notification by me; or by termination of services by me, or Big Brothers Big Sisters of the Tennessee Valley. A copy of this holds the same authority as the original.

I give my consent. I do NOT give my consent.

Social Media Consent

I hereby grant Big Brothers Big Sisters of the Tennessee Valley (BBBSTV) and its affiliates permission to identify my youth in any BBBSTV publication or production of media, in any form (digital, electronic, video, audio, photo, etc). I acknowledge that all rights, title, and interest to the media will belong to BBBSTV.

BBBSTV and its affiliates may use, reproduce, exhibit, or distribute any production of the media, in all form, for any purpose that the agency deems appropriate. This includes, but not limited to, promotional and advertising efforts.

I give permission for BBBSTV to post pictures or videos of my youth online.I do NOT give permission for BBBSTV to post pictures or videos of my youth online.

Mandatory Reporting

I , do hereby verify that Big Brothers Big Sisters of the Tennessee Valley staff has notified me that any volunteer matched with my child is now a Mandatory Reporter for the State. I understand that with the volunteer being a Mandatory Reporter, that any known or suspected abuse or neglect of a child must be reported to the proper authorities.

I accept I DO NOT accept

Smoking Cessation

For information about smoking cessation, please visit the CDC.gov.

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