Enroll A Child - Application

Participation Agreement

As the legal guardian of my child, I give full permission for the following:

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 transport my child to events and match activities.

For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);

3. To have my child participate in an in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests.

4. To have my child talk with a Big Brothers Big Sisters staff person about personal safety.

5. For BBBS staff to provide contact information for me and my child to the volunteer.

6. For Big Brothers Big Sisters staff to meet with my child at their school and/or afterschool program center to conduct an interview and/or match support.

7. I give permission for my child’s Big to meet with them at their school.

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 and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must 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 do hereby release the organization and its employees, agents, members, volunteers, and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating 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 his/her guardian. 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.

By clicking the checkbox below, I am agreeing that I have read, understood, and agree to the Participation Agreement.

I agree.

Confidentiality Agreement

1. All information that I may encounter about any child, child’s family, Big Brother/Big Sister, the Big Brother’s/Big Sister’s family or anything else of a confidential nature about any child or volunteer in any way connected with Big Brothers Big Sisters WILL BE HELD CONFIDENTIAL.

2. Any information that reveals or tends to reveal the identity of any person who is the subject of the record WILL BE HELD CONFIDENTIAL.

3. The identity of any person who contributes information to the subject record WILL BE HELD CONFIDENTIAL.

4. The results of any inquiry into school records or medical records of any description WILL BE HELD CONFIDENTIAL.

5. I will NOT discuss any information that I am privileged to receive with any other person without the verbal or written permission of the program staff.

6. I will only release prior approved information to the individual to whom I have been given permission to release the information.

7. I agree to hold all related information confidential and, except as I may be legally required, I will NOT disclose or release it to any individual or corporation at anytime.

8. I understand that Big Brothers Big Sisters agrees to hold all related information confidential and, except as we may be legally required, we will NOT disclose or release it to any individual or corporation at anytime.

By clicking the checkbox below, I am agreeing that I have read, understood, and agree to the Confidentiality Agreement.

I agree.

Media Release

I hereby grant Big Brothers Big Sisters Southern Lake Michigan Region (BBBS) the irrevocable right and permission to use photographs and/or video recordings of my child in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.

I understand and agree that such photographs and/or video recordings of my child may be placed on the Internet.

I also understand and agree that my child may be identified by first name only in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of my child.

I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Big Brothers Big Sisters Southern Lake Michigan Region.

I hereby release, acquit and forever discharge Big Brothers Big Sisters Southern Lake Michigan Region, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I understand that I can revoke this right in writing at any time and if I do not revoke this right, this release shall remain valid.

I consent to usage of video.I consent to usage of photos.I do not consent - please do not use photos, videos, or posting on social media.

Social Media Release

I understand and agree to abide by the Social Media Policy and all the policies contained therein. BBBS will not actively monitor the social media sites; however, if there is a complaint or inquiry, or BBBS becomes aware of a potential violation of this policy or any other, then BBBS has the right to access the social media site for compliance purposes.

YES, my youth has my permission to participate in parent-monitored, Internet-based social media communication with BBBS staff and the selected mentor.NO, my youth does not have permission to participate in the use of social media with regards to the match relationship proposed through BBBS.

Consent for Surveys

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.

Please note that BBBS matches Bigs and Littles based on interests, age, and location of both the Little and the Big. This means that we do not have a "traditional" waiting list and the length of time before a child is matched will vary. Once your child is accepted into the program, you may not hear from us until a potential volunteer has been identified. Once we have a potential volunteer who we think would be a great friend and mentor for your child, we will call you to schedule an interview and begin the enrollment process. You are welcome to call our office at any time with questions! Thank you for understanding!!

Electronic Signature

Please enter your full name:

Date

I understand that by typing my name and clicking on "Submit" that I am electronically signing this document.

I agree and sign this document.