Youth Application for Mentoring Programs

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In order for Big Brothers Big Sisters of Southwest Michigan to provide a responsible and professional service to clients it is necessary for volunteers, clients and parents or 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 the agency professional staff.  (Note:  These files are handled by clerical staff, both paid and volunteer.) The right to confidentiality applies not only to written records, but also to video, film, pictures, and use of client or volunteer’s name in agency publications.


All records are considered the property of the agency and not the agency worker, clients, or volunteers themselves.  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.


Clients and volunteers will be provided, at the time of application, a copy of this statement on confidentiality along with the exceptions which define the limits of confidentiality.  A client or volunteer shall sign a statement that he/she has read and understands the agency policy on confidentiality and agrees to program participation under the guidelines it sets forth.


Limits of Confidentiality

Information from client or volunteer records may be shared with the individuals or organization 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 photographs, 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 policies on confidentiality and may 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 share with match mates only after the involved parties agree to the match.



I agree to keep information discussed with me regarding a potential (Big Brother, Big Sister, Little Brother, Little Sister) match confidential.  I will not discuss this information with any person other than the assigned professional staff of the Big Brothers Big Sisters’ agency. 


I give permission for Big Brothers Big Sisters of Southwest Michigan to share the following information with a potential match mate, which may include: age of parent/child, marital status, race of the child, parent/child relationships, home environment, grade level, school performance, interests and activities, relationship with absent parent, expectations of parent, value systems, involvement with other agencies, self-assessment of parent/child and information from child interview.  Indicated below is the information I do not want shared with a potential match mate.  


I give my permission as the legal parent or guardian of the minor child referenced above, and irrevocably consent for myself and my child to any and all uses and displays of me or my 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, Big Brothers Big Sisters of Southwest Michigan, 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 my child, without any royalty, payment, or other compensation to me or my 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 give permission to have my child and myself complete questionnaires containing questions about peer relationships, feelings about school, grades, educational expectations, parental relationships and attitudes toward school. Please note: your child will still be eligible to receive services even if you decline to participate in the questionnaires.