Youth Enrollment Form - Community-based

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Non-Discrimination Policy
Our funders require that we collect the information in this form. It will not affect the youth’s enrollment.

Big Brothers Big Sisters of Metro Milwaukee does not discriminate on the basis of gender, race, color, physical condition, marital status, religion, sexual orientation, national origin or disability.
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Youth Information





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This is the year the youth will graduate.



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Guardian Information
















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Family Information



















Existing Household Members
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Emergency Contact
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Youth Personality Profile










Parent/Guardian Rules and Responsibilities

Big Brothers Big Sisters of Metro Milwaukee focuses on ensuring child safety, supporting Bigs and Littles in forming long lasting, positive relationships and helping youth reach positive outcomes. Please review each of the following statements to indicate you are aware of your responsibility, as a Parent/Guardian, to uphold the policies of Big Brothers Big Sisters of Metro Milwaukee.

Please review each policy and sign at the bottom of the page to acknowledge you have read and understand them.
Safety
OVERNIGHT POLICY - I understand Big Brothers Big Sisters (BBBS) does not allow overnight match activities. Violation of this rule will result in the closure of my child’s match.

MANDATED REPORTING - BBBS staff are mandated reporters. This means BBBS is required by law to report any signs of child abuse or neglect. The BBBS Emergency Line is available if I have a child safety concern or emergency needing support after hours.

SUPERVISION - I understand an adult (someone 18 or older) must be at home when my child is picked up and dropped off by his/her Big. I will ensure an adult is always there for pick-up and drop-off. I understand my child will be supervised by his/her Big at all times during their outings.

APPROPRIATE BEHAVIOR - I understand BBBS has a zero tolerance policy for illegal drug use. Smoking or consuming alcohol is STRICTLY PROHIBITED by my child’s Big before and/or during outings with my child. My child’s Big will always use appropriate language and model appropriate behavior when spending time with my child.

SAFE ACTIVITIES - My child’s Big will always choose safe and age-appropriate match activities and they will wear appropriate safety gear for activities such as biking, swimming, or boating.

TRANSPORTING YOUTH
  • I understand BBBS follows Wisconsin laws and recommendations that children ages 4-7 must sit in the backseat in a booster seat, and all children must sit in the backseat until age 13. Seat belts are required at all times for Bigs and Littles. I will be supportive of this recommendation and provide a booster seat for the Big to use, if needed.
  • I understand my child’s Big is the only person authorized to transport my child unless approved in advance by me and my Match Support Specialist (MSS).
  • I understand BBBS policy prohibits the use of a cell phone when driving my chlid. Bigs are required to pull over and safely stop the vehicle before using a cell phone.
  • I understand BBBS requires Bigs to maintainliability auto insurance coverage as required by the State of Wisconsin. Bigs are required to notify BBBS and me if their driving privileges or auto insurance coverage changes.
BACKGROUND CHECK - I understand annual background checks, including electronic media, driving records check and criminal background screening will be conducted by BBBS on my child’s Big.

FIREARMS AND WEAPONS - I understand my child’s Big is to never carry or possess a weapon at any time on their person or in their vehicle while in the company of my child. If my child’s Big owns weapon(s), they will keep all weapons locked and inaccessible to my child. Hunting or shooting a firearm is not an approved BBBS match activity for my child to participate in with his/her Big.

MEMBERSHIP/EMERGENCY CARD - I understand the back of this card provides emergency contact, doctor and allergy information for my child. I will ensure the information is up-to-date and my child’s Big will carry this card with during each outing with my child.
Match Support
MATCH SUPPORT CONTACT - I understand keeping in touch with my MSS is a requirement of the program. BBBS requires me to be in contact with my MSS every 30 days during the first year of my child’s match and at a minimum every 90 days thereafter. I will be prepared to discuss the outings in which my child participates, how the relationship is developing with my child’s Big and how often they meet. I will return contact attempts made by my MSS. Match support is a service provided by BBBS to help support my child’s match and monitor my child’s safety in the match.

CONSEQUENCES - I understand lack of communication with my MSS will result in my child’s match being closed if we are not in compliance with BBBS standards.

CONCERNS - I understand that if I have concerns or a problem arises in my child’s match I will contact my MSS immediately.

GOAL SETTING - I will work with my child, my child’s Big and my MSS to set goals for my child related to achieving educational success, avoidance of risky behaviors, higher aspirations, greater confidence, and better relationships.

UPDATES/CHANGES - I understand I must contact my child’s Big and my MSS promptly regarding any change in my address, phone number or email as well as changes that arise in our life.
Friendship
COMMITMENT AND FREQUENCY - I understand my child and his/her Big are expected to have 2 to 4 outings/activities per month for approximately and maintain weekly communication. Outings/activities can be virtual, in-person (following BBBS guidelines), or a combination of virtual and in-person. I will provide prior approval for my child to have more than 2 outings in one week’s time or an outing exceeding 6 hours with his/her Big. I understand BBBS encourages long-lasting relationships, and matches can remain open until my child turns 18, graduates high school, or through the first year of their post-secondary. Matches can continue through our Post-Secondary Program (PSP) for 1 year following Little’s high school graduation.

ONE-TO-ONE - I understand the focus of the BBBS program is one-on-one time between my child and his/her Big. I will not ask my child’s Big to bring along other children on their outings and I will approve all outings in which others are included (ex: Big’s significant other).

COMMUNICATION - I understand communication with BBBS and my child’s Big is key to the success of their match. I will discuss and provide permission to my child’s Big for each match activity. I will maintain weekly phone and in-person communication with my child’s Big and monthly communication with BBBS.

RESPECT - I understand my child’s Big and my family may come from different backgrounds. I will be open-minded and non-judgmental regarding my child’s Big. I will show respect to my child’s Big at all times and will contact my MSS with any questions or concerns.

PUNISHMENT - I understand that consistent contact between my child and his/her Big is in my child’s best interest. Therefore, I will not take away my child’s outings with his/her Big as punishment. If my child needs to be disciplined, I will speak with my child’s Big about the situation and work together to determine an appropriate outing/activity that takes into account my child’s misbehavior.
Boundaries
PERSONAL SPACE - I understand physical contact including, but not limited to, backrubs, sitting on laps, wrestling, rough housing or tickling is not allowed between my child and his/her Big. Affection is best expressed through positive affirming comments. My child’s Big is only allowed to express physical affection after obtaining my child’s permission. Physical affection may be expressed using a handshake, high-five, pat on the back or hug. I will contact my MSS immediately if I have any concerns about contact between my child and his/her Big.

INAPPROPRIATE MATERIAL - I understand my child’s Big will never display inappropriate materials or initiate discussions of a sexual nature with my child.

PHOTOS - I have the right to view any photos my child’s Big takes on their outings and my child’s Big is never allowed to photograph my child in his/her bathing suit, undergarments, or without clothing.

PRIVATE RESTROOMS/CHANGING AREAS - My child’s Big will always provide separate/private areas for my child to use the restroom and/or change clothes. My child’s Bigs is never allowed to bathe, shower or swim nude with my child.

DISCIPLINE - My child’s Big is not allowed to use physical contact or abusive language to correct my child’s behavior. If my child misbehaves during an outing, my child’s Big can state expectations for behavior and verbally address behavior concerns. If my child does not respond, my child will be returned home and I will be informed of the situation.

ACTIVITIES AT VOLUNTEER’S HOME
  • 3 MONTH WAITING PERIOD - My child is not allowed to visit his/her Big’s home during the first 3 months of their match. Once my child has been matched for at least 3 months and with my approval, they may have an activity in his/her Big’s home.
  • APPROPRIATE ROOMS - I understand that my child should never enter his/her Big’s bedroom or any other bedrooms in the Big’s home. Appropriate areas for activities are kitchen, living room or other common areas.
LOW/NO-COST ACTIVITIES - I understand BBBS encourages my child’s Big to plan inexpensive or no-cost outings. I will provide money for outings only if I am able, but I understand this is not an expectation of the program. I will not ask my child’s Big to provide expensive activities or buy things for my child.

GIFT GIVING - I understand gift giving is not an expectation of the program and should be limited to special occasions such as a birthday, holiday, special event or recognition of my child’s achievement. I will approve any gift purchased for my child and I understand BBBS limits the amount of a gift or special activity to $50 or less. Gifts should never be purchased for my child and kept at the Big’s home without my permission.

COMMUNICATION/RELATIONSHIP - I understand it is important to have a healthy relationship between myself and my child’s Big and I will not develop a personal relationship with my child’s Big. I will not ask my child’s Big to provide funds, run errands or serve as a resource for my family. I understand that BBBS has many resources and I should contact my MSS if I need assistance.
I indicate that I have read the agency rules and policies and I understand and agree to my responsibilities outlined above.  
Parent/Guardian Acknowledgement

Medical Release

I authorize Big Brothers Big Sisters (BBBS) employees, and/or BBBS volunteers to consent to such medical and/or surgical treatment as he/she deems necessary for my child in case of emergency, illness of my child, or accident involving my child. If possible under the circumstances, these medical services are to be performed by the below named physician or facility.




Parent/Guardian Acknowledgement

Virtual Communication Platform Consent

Big Brothers Big Sisters has developed a digital platform to help Bigs and Littles stay in touch in a safe and secure way. Participation in this platform and use of other electronic communication tools requires permission.

I consent for the youth to having contact with his or her Big and/or BBBS staff through Big Brothers Big Sisters' digital platform.

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 Metro Milwaukee (BBBSMM) on BBBSMM and NATIONAL websites, including bbbsmilwaukee.org, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. BBBSMM COPPA statement is incorporated in the website Privacy Policy here. BBBSMM 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 ETC.] You have the right to revoke your consent at any time for the collection and use of your child’s information. If you would like to revoke your consent, please provide a written, signed statement of revocation and mail it to: Big Brothers Big Sisters of Metro Milwaukee, 788 N Jefferson Street Suite 600, Milwaukee, WI 53202.

Parent/Guardian Acknowledgement

Confidentiality Policy

Big Brothers Big Sisters of Metro Milwaukee respects the confidentiality of all program participants’ (defined as Parent/Guardian/Caregiver, Child and Volunteer) records and, with the exception of situations listed below, shares information about program participants only among agency professional staff. In order to provide service, 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 program participants. It is the agency’s responsibility to protect the confidentiality of reference responses and counseling reports by not disclosing their content to a participant applicant. Therefore, the agency will not disclose the reason for non-acceptance to the potential program participant.

All records are considered the property of the agency and not the agency workers or program participants themselves. Records are not available for review by the program participants. All program participants must sign this summary statement indicating an understanding of the agency’s confidentiality policy and agree to program participation under the guidelines before being accepted into the program.

Information will be released to other individuals or non-BBBS organizations only with the program participants’ written consent. Identifying information regarding program participants may be used in agency publications or promotional materials unless the client requests 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 program participant records. Members of the Board of Directors or evaluators appointed by the Board have access to program participant files upon authorization of the Board of Directors. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena. Information shall be provided to an agency's legal counsel in the event of litigation or potential litigation involving the agency.

State law mandates suspected child abuse be reported to the appropriate authorities (Bureau of Milwaukee Child Welfare, Waukesha County Dept. of Health & Human Services and/or local law enforcement agency). If an agency staff receives information indicating that a program participant may be dangerous to him/herself or to others, necessary steps will 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 by the agency with 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/parent may include such items as: age, sex, race, religion, interests, hobbies, family situation, sexual orientation, living situation etc.

I understand that some information, including opinions of the agency staff, may be shared with parents of a potential Little Brother or a Little Sister or a potential volunteer. I hereby give my authorization for such limited release and use of information that may otherwise be deemed confidential pursuant to the policies contained in the complete confidentiality policy statement and I release and waive any liability against the organization, all Big Brothers Big Sisters staff and the Board of Directors of said organization.

I have read and understand the above document which summarizes the agency policy of confidentiality of client records. I agree to abide by the conditions it sets forth.
Parent/Guardian Acknowledgement

Communicable Disease Policy

Big Brothers Big Sisters of Metro Milwaukee’s (BBBS) decisions involving persons who have communicable diseases shall be based on current and well-informed medical judgments concerning the disease, the risks of transmitting the illness to others, the symptoms and special circumstances of each individual who has a communicable disease, and a careful weighing of the identified risks and the available alternative for responding to a Volunteer or Child with a communicable disease.

Communicable diseases include, but are not limited to, measles, influenza, viral hepatitis-A (infectious hepatitis), viral hepatitis-B (serum hepatitis), human immunodeficiency virus (HIV infection), AIDS, AIDS-Related Complex (ARC), leprosy, Coronavirus (COVID-19), Severe Acute Respiratory Syndrome (SARS) and tuberculosis. BBBS may choose to broaden this definition within its best interest and in accordance with information received through the Centers for Disease Control and Prevention (CDC).

BBBS will not discriminate against any Volunteer or Child based on the individual having a communicable disease. BBBS reserves the right to exclude a person with a communicable disease from the programs and functions if the organization finds that, based on a medical determination, such restriction is necessary for the welfare of the person who has the communicable disease and/or the welfare of others.

BBBS will comply with all applicable statutes and regulations that protect the privacy of persons who have a communicable disease. Every effort will be made to ensure procedurally sufficient safeguards to maintain the personal confidence about persons who have communicable diseases.
I have read and understand the above policy, which states the Big Brothers Big Sisters agency policy with respect to communicable diseases of the program participants. I agree to participate in the program and comply with the conditions set forth above.
Parent/Guardian Acknowledgement

Media Release and Consent Form

I, as the legal parent or guardian of the child listed below, 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 Metro Milwaukee 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 Media Consent and Release Form completely and I fully understand what it means. 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.
Youth's Name

Parent/Guardian Acknowledgement

Electronic Signature

I give permission:
  • for the youth to participate in the Big Brothers Big Sisters of Metro Milwaukee (BBBS) program.
  • for the youth to complete surveys containing questions about topics including personal interests, peer relationships, feelings about school, grades, educational expectations, parental relationships, home life and attitudes toward risky behaviors.
  • for the youth's school to release information about academic performance, behavior and grades to BBBS.
I understand that:
  • BBBS is not obligated to match the youth with a volunteer.
  • As part of the enrollment process the youth and I will be asked to provide additional personal information about the youth and my family.
  • BBBS may share pertinent information with a volunteer to appropriately match the youth.
  • If the youth is matched with a Big Brother or Big Sister I will support the match and immediately report any concerns I might have to the BBBS staff.
  • Neither the agency nor the volunteer assumes legal or financial responsibility.
  • BBBS staff are mandated reporters. This means BBBS is required by law to report any signs of child abuse or neglect.
I acknowledge that I have completed this enrollment form and that all information is correct to the best of my knowledge.

I have read and understand documents containing policies in the enrollment form including, but not limited to:
  • Non-discrimination Policy
  • Parent/Guardian Rules and Responsibilities
  • Medical Release
  • Virtual Communication Platform Consent
  • Confidentiality Policy
  • Communicable Disease Policy
  • Media Release
PLEASE NOTE - After submitting this form with the electronic signature on the next page, you will receive an email with a link to verify the signature. YOU MUST CLICK THE LINK TO VERIFY SUBMISSION IN ORDER FOR THE FORM TO BE COMPLETE.
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