In-School Mentoring+ Application Form - YRDSB & SCDSB - Big Brothers Big Sisters of Peel York

THIS FORM WILL TAKE BETWEEN 10-30 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.

CHILD'S INFORMATION

Child's Name*

First Last

Preferred Name (if applicable)

Date of Birth*

Gender Identity*

Pronouns

School Name*

Grade*

Teacher*

PRIMARY CAREGIVER'S INFORMATION

Please 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

Email*

Mobile Phone*

Address*

Street Address Address Line 2 City Province Postal Code

Who lives in the same household as your child?*

Please identify their relationship to your child.

GETTING TO KNOW YOUR CHILD

Please select the character trait(s) that best describe your child*

Select all that apply.

Friendly

Outgoing

Shy

Withdrawn

Active

Helpful

Imaginative

Please check any of the following that describe your child's interests:*

Select all that apply.

Why does your child want a Mentor?*

What academic areas/subjects would you want the Mentor to help your child with? (i.e., math, reading, science)*

What class(es) would you rather your child not miss?*

Is there anything you would like us to be aware of that would assist us in finding the right Mentor for your child?

Please describe.

Does your child have any allergies, medical conditions, special needs, learning disabilities or other concerns that we should be aware of?*

Yes

No

If yes, please describe:

Is your child currently receiving or have they in the past received any support from other agencies, schools, psychiatrists, social workers, children’s aid societies, etc.?*

Yes

No

If yes, please describe:

Please select the most important factors for your child at this time. You are welcome to select any that apply*

YOUR INVOLVEMENT

This program takes place on school property only. For that reason, you do not have to be involved in any way. However, if you would like to meet with your child’s Mentor, learn more about them, or receive updates about your child’s mentoring relationship, please contact your BBBSPY Caseworker or your child’s school. When contacting the Caseworker, please include your child’s name and their school’s name.

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 (BBBSPY) 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, however, where appropriate supervision takes place, the volunteer may be younger) 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 BBBSPY, 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 BBBSPY, 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 BBBSPY is under no obligation to provide my child with a Mentor and that this application is the property of BBBSPY. I also agree that my child will participate in the Pre-Match Training Program administered by BBBSPY.*

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*

OPTIONAL SECTION: STATISTICAL INFORMATION

At 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 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:

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.

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?

Comments

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

In-School Mentoring+ Application Form – YRDSB & SCDSB

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