Virtual Wellness Warriors – Registration Form

Virtual Wellness Warriors is a gender-inclusive group mentoring program for children and youth in grades 6-8. Facilitated by trained Mentors, Mentees are provided with the opportunity to engage in fun and interactive discussions and activities. The program promotes mental, physical, and social wellness. It is delivered once a week via zoom for 7 consecutive weeks.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Child's Name*
MM slash DD slash YYYY
This response is voluntary.
First and Last
Relation to Child*

Family Address*
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.
Does your child have any dietary considerations?*
We ask because some of the group discussion will be on healthy balanced eating and we want to make sure we are sensitive to each participant’s dietary needs when holding these discussions.
Ex. religious or cultural views, stressors, other existing issues?
Can Your Child Have Independent Access to Zoom?*
All sessions will take place virtually over Zoom video conferencing. In order to participate, your child will need private access to the Zoom app for each session.

Online Program Consent

As the parent/guardian, I understand the following rules, which will be reinforced during the first session and periodically throughout the program: 1. Participants and Mentors are not permitted to share information about one another outside of the group 2. The chat function will be set so that all comments will be visible to the Mentors and no private chats between participants will be possible 3. Participant and Mentor contact will be limited to the pre-scheduled sessions 4. Any communication that occurs outside of scheduled meetings cannot be supervised by Mentors or BBBSPY staff and are therefore under my discretion and supervision as the parent/guardian. As the parent/guardian, I agree to: 1. Support and encourage my child to participate in each session 2. Provide support or feedback to the Mentors if required 3. Check in with my child following each session to determine how they are responding to the program 4. Contact BBBSPY immediately should any concern arise from my child’s participation in this program
By checking YES you providing your consent for your child to engage in the Virtual Wellness Warrior Program. You are also giving your consent for your child to have virtual contact with other group participants and trained Mentors during program sessions*
You are encouraged to review Zoom’s privacy policy which can be found here: https://zoom.us/privacy. Each program is supported and monitored by a BBBSPY Program Staff member.

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 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.*

Informed Consent

I 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.*
Clear 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).
Child's Birth Place