Community Based Mentee Application

Dear parent/guardian:

Thank you for your inquiry for a Big Brother or Big Sister for your son or daughter.

Big Brothers Big Sisters of Dufferin & District is a non-profit agency whose mission is to enable life-changing mentoring relationships to ignite the power and potential of young people.

We try our utmost to match Little Brothers and Sisters and Big Brothers and Sisters whose interests, personalities, and needs/skills are just the right mixture for a fun, supportive and enjoyable relationship. This is a special relationship that will help your son or daughter attain the goals that you and our agency agree to, whether that be improving self esteem, self-awareness, or increasing activity level or maturity.

When we receive your completed application we will call you and your young person for an in-office interview. In this way, we are able to get to know the two of you and match your son or daughter with a compatible Big Brother or Big Sister.

In the meantime, once you have been approved for our program, your son or daughter is welcome to join in our special activities just for unmatched Little Brothers and Little Sisters. Last year, these children took part in such things as hikes, fishing, and a Halloween party.

We look forward to meeting you and your young person soon. If you have any questions, please do not hesitate to call us at (519) 941-6431.

Sincerely,

Kaleigh Watson (Mentoring Coordinator)

kaleigh.watson@bigbrothersbigsisters.ca

519-941-6431 ext. 202

Nancy Stallmach, (Executive Director)

nancy.stallmach@bigbrothersbigsisters.ca

519-941-6431 ext. 200

Media Consent - Young Person

Name of Young Person

First Last

Any photographs or video productions taken of children or youth by agency staff at recreational events or match outings, or otherwise authorized by the Executive Director or Board of Directors, may be used by the agency for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners for program promotion.(Required)

Yes, I give Media Consent

If you do not want your picture or your young person’s picture used or if you have a safety concern

Signature

It is the parent/guardian’s responsibility to notify the office if the status of this consent changes.

Informed Consent

I hereby make formal application to Big Brothers Big Sisters of Dufferin & District to make available their service to my young person. It is my understanding that the intention of the Agency is to match a responsible male/female adult, (minimum 18 years old), with my young person 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 young person. In consideration for this service and other valuable consideration provided to my young person by Big Brothers Big Sisters of Dufferin & District, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my young person. 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 consent to Big Brothers Big Sisters of Dufferin & District contacting any referring professionals involved with my family to obtain information for the purpose of assessing my application for a Mentor. I further agree that all or part of the information herein may be shared, at the discretion of Big Brothers Big Sisters of Dufferin & District, with my young person’s Mentor, and/or with the referring professional, so that my young person’s needs in a Mentoring relationship may be best met. I understand that the collection of personal information about me or my young person will be held in strict confidence and is to be used solely for the purposes of administering the program. I understand that I am under no obligation to accept a Mentor for my young person, that the Agency is under no obligation to provide my young person with a Mentor and that this application is the property of Big Brothers Big Sisters of Dufferin & District. I also agree that I and my young person will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of Dufferin & District.(Required)

I, the parent/guardian hereby request of hereby request Big Brothers Big Sisters service for my young person. I give the agency my consent to assign a Mentor to my young person. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my young person.

Parent/Guardian Signature(Required)

It is the parent/guardian’s responsibility to notify the office if the status of this consent changes.

Optional Section: Statistical Information

At Big Brothers Big Sisters of Dufferin and District, 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. Filling out this section 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).

Languages 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 new 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:

Comments

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

bigbrosbigsisofdufferin

Community Based Mentee Application

Child's Information

Parent / Guardian Information

Other Parent

Family history / situation

Medical History

Relationships

Social Activities

About Big Brothers Big Sisters

Confidentiality

Media Consent - Young Person

Informed Consent

Optional Section: Statistical Information