BBBSPY Mentee Application BBBSPY Mentee Application Form "*" 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 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 the Black Community) Big Sisters BCAC Big Sisters (Available to Mentees and Mentors from the Black Community) Big Buddy(Male Mentees matched with Female Mentors) Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code 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 I am the individual listed above and the legal guardian of the child for whom I am making this application.* Yes No Relationship to child* Mother Father Other 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 youd 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.MEDIA CONSENTI 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 during the program as 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.* YES, I give media consent NO, I do not give media consent INFORMED CONSENTI 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 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 further agree that information about my child may be shared, at the discretion of Big Brothers Big Sisters of Peel York, with my child’s Mentor so that my child’s needs in a Mentoring relationship may be best met. 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 my child will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of Peel York.* 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* Facebook Twitter Google+ LinkedIn