BBBSPY Mentee Application

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 CRITERIA

Before 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 students could result in the termination of my child’s application and/or the closure of their file.

YOUR INVOLVEMENT

You 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

CONFIDENTIALITY

Just 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.

MEDIA CONSENT

I hereby consent to Big Brothers Big Sisters of Peel York (BBBSPY), the use of any photographs, audio and/or video recordings of my child taken by the agency at recreational events or match outings, or otherwise authorized by the BBBSPY President & CEO or Board of Directors. I give my permission for this media to be used by BBBSPY for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions, and digital media, (such as the BBBSPY website and social media). Photographs or video productions may also be shared with community and school partners for program promotion. Note: It is the caregiver’s responsibility to notify the office if the status of this consent changes.*

YES, I give media consent

NO, I do not give media consent

INFORMED CONSENT

I 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.

ATTESTATION

I 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*

Phone

This field is for validation purposes and should be left unchanged.