BBBSPY Mentee Application "*" indicates required fields Step 1 of 5 20% THIS FORM WILL TAKE BETWEEN 20-40 MINUTES TO COMPLETE.In order to keep the information private and secure this application must be completed all at once and cannot be saved in stages. Please make sure you have enough time before starting the application. Thank you.MENTEE ELIGIBILITY CRITERIABefore completing the application, please review and complete the following checklist.Each box must be checked in order for your application to be considered complete. I understand that I must be the primary care provider of the child I am enrolling. I understand that Big Brothers Big Sisters of Peel York is under no obligation to accept my child/provide my child with a Mentor. I understand that all applicants must be between the ages of 6 to 17 years old. I understand that the time between application and program involvement could be between 3-12 months. I understand that my child must be able to communicate and manage self-care independently. I understand that my child must be able to comprehend child safety messages that will be delivered through a Pre-Match Training. I understand that my child must not have any major presenting behaviours that could put them or others in the program(s) at risk of harm. I understand that my child must be able to build a relationship with an adult Mentor that is positive, healthy, and respectful of boundaries. I understand that while I may have one key contact at the agency, there is a team of Caseworkers as well as trained students from the Enhanced Student Placement Program who may be in contact with me and my child throughout our participation in the program(s). I understand that I will be required to be an active participant in the match, and that I am expected to maintain communication with the Caseworkers and/or students; including regularly scheduled telephone, email, and in person meetings. I understand that my inability to maintain this contact with the Caseworkers and/or Placement Students could result in the termination of my child’s application and/or the closure of their file. CHILD'S INFORMATIONChild's Name* First Last Preferred Name (if applicable) Date of Birth* MM slash DD slash YYYY Gender Identity* Pronouns Please select the program you are MOST interested in for your child* Big Brothers BCAC Big Brothers (Available to Mentees and Mentors from Black Communities) Big Sisters BCAC Big Sisters (Available to Mentees and Mentors from Black Communities) Big Buddy (Self-Identifying Male Mentees matched with Self-Identifying Female Mentors) Address* Street Address Address Line 2 City Province Postal Code Country CanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands School Name* Grade* How does your child get along with other children?*Who are the significant adults in your child's life?*Please outline their relationship to your child and the frequency of their interaction. What activities does your child enjoy doing outside of school?*Please select the character trait(s) that best describe your child*Select all that apply. Highly active Friendly Outgoing Helpful Quiet Shy Withdrawn What do you hope your child will gain from their involvement with our program?*Please select the most important factors for your child at this time. You are welcome to select any that apply* Enhance interpersonal relationship skills Increase self-awareness and self-management Healthier, more responsible decision making Increase self-confidence and self-esteem Improve mental health Develop coping strategies and resilience Sense of belonging School connectedness Improve educational engagement More constructive use of time Please describe the ideal Mentor for your child*I.e. gender, age, personality type, interests, ethnicity, languages spoken, etc. PRIMARY CAREGIVER'S INFORMATIONPlease provide your information in this section. Primary Caregiver's Full Name*First and Last Relationship to child* Mother Father Other I am the individual listed above and the legal guardian of the child for whom I am making this application.* Yes No Mobile Phone*Email* Does your child live with you?* Yes No If No, please enter your addressOnly required if different from the address provided above. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Significant Other/Partner Status* Single In Committed/Long Term Relationship Married Common Law Separated Divorced Widowed Are you anticipating any changes in your life in the next year?*I.e. marital status, change of address, employment, etc. Yes No If Yes, please specify OTHER CAREGIVER'S INFORMATIONPlease describe the relationship you and your child have with their other caregiver/guardian.*If not applicable or no relationship exists, please state that. What is the existing parenting arrangement?* Not applicable/lives with both parents I have Sole Decision-Making Responsibility I have Joint Decision-Making Responsibility I have De Facto Decision-Making Responsibility Currently under review Other Other Caregiver's Full NameFirst and Last Is your child's other caregiver supportive of your agency involvement? Yes No EMERGENCY CONTACT INFORMATIONPlease list someone other than yourself.Emergency Contact's Full Name*First and Last Relationship to your child* Emergency Contact's Phone*FAMILY HISTORYLanguage(s) Fluently Spoken* Family Type*Single Parent FemaleSingle Parent MaleLives with Both Biological ParentsTwo Parent Blended FamilyAdoptive ParentsGrandparentKinship CareFoster HomeGroup HomeLiving IndependentlyCustodial FacilityTransientWho lives in the home with the child?*Does your child have any mental health concerns or diagnoses?* Yes No If Yes, please provide detailsDoes your child have any allergies?* Yes No If Yes, please provide details, including actions to be taken if contact with allergen is made.Please be sure to note if your child requires/carries an EpiPen.Does your child have any physical considerations that we should be aware of for accessibility reasons?* Yes No If Yes, please provide detailsIs your child taking any prescribed medications?* Yes No If Yes, please provide detailsAre there any other agencies involved in your family's care?*E.g. Children's Aid Society, Counsellor, Psychiatrist, Social Worker, etc. Yes No If Yes, please provide the name and contact information for your support workerHave you or your family ever been involved with Big Brothers Big Sisters before?* Yes No YOUR INVOLVEMENTYou know your child better than anyone. Although this relationship is primarily between your child and their Mentor, we encourage you to take an active role in the match by providing support and strategies to the Mentor. This will help them build a meaningful connection with your child. We will also need your assistance with ensuring your child is prepared and on time for their meetings. Finally, our trained staff will monitor and support your child’s match from the very beginning. It is imperative for the safety and health of the match that our monitoring schedule is adhered to. Please do your very best to reply to calls, emails, and meeting requests in a timely manner.Do you agree to support this match to the best of your ability?* Yes No CONFIDENTIALITYJust as we have to share information with you about the Mentor we select for your child, we need to share information with the volunteer about you and your child.If there is anything that you do not want shared with your child's Mentor, please list it below.INFORMED CONSENTI confirm that I am the legal guardian of the child for whom I am applying and have legal decision-making responsibility for this child. No other persons’ signature is required, other than my own, to make this a legally binding release for this child. I hereby make formal application to Big Brothers Big Sisters of Peel York to make available their service to my child. It is my understanding that the intention of the Agency is to match a responsible adult, (minimum 18 years old), with my child for the purposes of shared activities, friendship, and support. I understand that all efforts will be made to select a Mentor who is compatible with my child. In consideration for this service and other valuable consideration provided to my child by Big Brothers Big Sisters of Peel York, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof. I consent to Big Brothers Big Sisters of Peel York contacting any referring professionals involved with my family to obtain information for the purpose of assessing my application for a Mentor. I further agree that all or part of the information herein may be shared, at the discretion of Big Brothers Big Sisters of Peel York, with my child’s Mentor, and/or with the referring professional, so that my child’s needs in a Mentoring relationship may be best met. I understand that the collection of personal information about me or my child will be held in strict confidence and is to be used solely for the purposes of administering the program. I understand that I am under no obligation to accept a Mentor for my child, that the Agency is under no obligation to provide my child with a Mentor and that this application is the property of Big Brothers Big Sisters of Peel York. I also agree that I and my child will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of Peel York. Note: Release to share information with other professionals will expire within one year of the date application submitted.* Yes. I have read and understand this agreement. I acknowledge that I am the parent/guardian of the child for whom I am applying and that I hereby request Big Brothers Big Sisters service for my child. I give my consent to assign a Mentor to my child. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child. ATTESTATIONI hereby confirm that I am the legal guardian of the child for whom this application is being made. I further attest that the information provided here is true and complete to the best of my knowledge.* Yes No Signature*OPTIONAL: SOCIAL IDENTITY DATAAt Big Brothers Big Sisters of Peel York, statistical information is requested from volunteers and families for the purpose of better understanding the community in which we serve, and for acquiring funding from community supporters and donors. This allows us to provide culturally responsive and high-quality services at no cost.Please note: Filling out this portion of the application form is optional. If you choose to complete it, the information you provide below will be kept confidential and will in no way affect your child’s eligibility to participate in our program(s). Child's Birth Place Canada Other If your child was born outside of Canada, please provide the year they moved to Canada. Please select the ethnic/cultural origin that you feel best describes your child or use the next field to enter it directly.Prefer not to sayAsian - East (e.g., Chinese, Japanese, Korean descent)Asian - South (e.g., Indian, Pakistani, Sri Lankan descent)Asian - South East (e.g., Malaysian, Filipino, Vietnamese descent)Black - African (e.g., Ghanaian, Kenyan, Somali descent)Black - Caribbean (e.g., Barbadian, Jamaican descent)Black - North American (e.g., Canadian, American descent)First NationsIndian - Caribbean (e.g., Guyanese with origins in India)InuitLatin American (e.g., Argentinean, Chilean, Salvadorian descent)MétisMiddle Eastern (e.g., Egyptian, Iranian, Lebanese descent)White – European (e.g. English, German, Italian descent)White – Middle EasternWhite – North American (e.g. Canadian, American)If none of the options above accurately reflect your child's identity, please feel free to add a note here: What is the total annual household income?Prefer not to answerBelow $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - $50,000$50,001 - $75,000over $75,000NameThis field is for validation purposes and should be left unchanged. 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