Black Youth Mentoring Registration Form "*" indicates required fields Thank you for your interest in Black Youth Mentoring. Once your submission has been reviewed by our team, you will receive an email confirmation with more details about the program.PERSONAL INFORMATIONYouth's Name* First Last Youth's Date of Birth* MM slash DD slash YYYY Youth's Gender Identity* Parent/Guardian's Name* First Last Relation to Youth* Mother Father Other Parent/Guardian's Phone Number*Parent/Guardian's Email Address* I am the parent/guardian of the child for whom I am making this application.* Yes No How did you hear about this program?* I've always known My child's school told me about it I found it on the BBBSPY website I heard through another community group/agency Word of mouth Other Family Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code EMERGENCY/ALTERNATE CONTACTAlternate Contact Name*Please provide an alternate contact to call in case of emergency. First Last Alternate Contact Phone Number*ADDITIONAL INFORMATIONPlease describe your child’s personality.*What activities does your child enjoy doing outside of school?*Does your child have any medical or behavioral needs that we should be aware of?*We realize that this information can be of a sensitive nature and it will be treated with confidence and respect. Yes No If yes, please provide details.Are there any adaptations that can be made with regard to these needs in order to best support your child?Does your child have any dietary considerations?*I.e. Allergies, intolerances, faith-based requirements, etc. Yes No If Yes, please provide details.Is there any other information you would like the Mentors/volunteers to know about your child?Ex. religious or cultural views, stressors, other existing issues?We do not always have the programming or volunteer training to support the needs of every child. We may be in touch in regards to your child’s application if we have any questions.PROGRAM SITEPlease select the appropriate program location.*Please note that guardians are responsible for pick-up and drop off. University of Toronto Mississauga Campus TM (3359 Mississauga Road Mississauga) Sheridan College Davis Campus (7899 McLaughlin Road, Brampton) 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 give permission 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 offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. 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 the group facilitator so that my child’s needs may be best met. I understand 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 child permission to participate in one or more group programs offered by BBBSPY. 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. Parent/Guardian SignatureSignature*OPTIONAL SECTION: SOCIAL IDENTITY INFORMATIONAt 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 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).Language(s) Spoken Youth'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 say Black - African (e.g., Ghanaian, Kenyan, Somali descent) Black - Caribbean (e.g., Barbadian, Jamaican descent) Black - North American (e.g., Canadian, American descent) If none of the options above accurately reflect your child's identity, please feel free to add a note here: What is the total 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. Facebook Twitter Google+ LinkedIn
