Black Youth Mentoring Registration Form - Big Brothers Big Sisters of Peel York

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 INFORMATION

Child's Name*

First Last

Child's Date of Birth*

Child's Gender Identity*

Child's Ethnic Identity

This response is voluntary and will be used for statistical purposes only.

Black - African

Black - Caribbean

Black - North American

Mixed Heritage

Prefer Not To Disclose

Other

Child's Birth Place

This response is voluntary and will be used for statistical purposes only.

Canada

Other

Child's School*

Parent/Guardian's Name*

First Last

Relation to Child*

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

Is your child currently involved with Big Brothers Big Sisters of Peel York?*

Yes

No, this will be their first time participating in a BBBSPY program

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 Province Postal Code

EMERGENCY/ALTERNATE CONTACT

Alternate Contact Name*

Please provide an alternate contact to call in case of emergency.

First Last

Alternate Contact Phone Number*

ADDITIONAL INFORMATION

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

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 food allergies or restrictions?*

Yes

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?

PROGRAM SITE

Please 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 Consent

I hereby consent to Big Brothers Big Sisters of Peel (BBBSP)

The use of any photographs, audio and/or video recordings of my child taken during the program as authorized by the BBBSP President & CEO or Board of Directors. I give my permission for this media to be used by BBBSP for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the BBBSP website and social media). Photographs or video productions may also be shared with community and school partners for program promotion. Please select your response to the Media Consent statement listed above.

YES, I give Media Consent

NO, I do not give Media Consent

Informed Consent

I hereby give permission to Big Brothers Big Sisters of Peel (BBBSP)

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), 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 BBBSP, 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 BBBSP, with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of BBBSP. I also agree that my child will participate in the Pre- Match Training Program administered by BBBSP. I have read and understand this agreement. By checking YES, 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 BBBSP. 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.

YES

Parent/Guardian Signature

Signature*