In-School Mentee Application Form Child's InformationChild's Name(Required) First Last Child's Date of Birth(Required) MM slash DD slash YYYY Child's Gender Identity(Required) Child's School(Required) Grade(Required) Teacher(Required) Family Address(Required) Street Address Address Line 2 City Postal Code Parent/Guardian's Full Name(Required) First Last Relation to Child(Required) Father Mother Other Parent/Guardian's Phone Number(Required)Parent/Guardian's Email Address(Required) I am the parent/guardian of the child for whom I am making this application(Required) Yes No Please check any of the following characteristics that describe your child Friendly Outgoing Shy Withdrawn Active Helpful Please check any of the following that describes your child's interests Cooking Music Board / Card Games Building (Lego / Play-doh) Sports Animals Arts / Crafts Reading / Books Movies / TV Talking Does your child have any medical or behavioral needs that we should be aware of?(Required)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 detailsWhat classes 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? Your InvolvementEvery child in the program participates in pre-match training. Would you like to recieve a copy of the material prior to your child participating? Yes No Would you like to recieve email updates about the mentoring relationship? Yes No Media ConsentI allow Big Brothers Big Sisters of Dufferin and District the use of any photos of my child taken during Go Girls! as authorized by the BBBSDD Board of Directors. I give my permission for this media to be used by BBBSDD for purposes of promotional materials including newsletters, the BBBSDD website, and social media. Photographs or video productions may also be shared with community and school partners for program promotion and continued funding.(Required) Yes, I give Media Consent No, I do not give Media Consent Informed ConsentI hereby make formal application to Big Brothers Big Sisters of Dufferin & District (the “Agency”) to make available their service to my child. It is my understanding that the intention of the Agency is to match a responsible male/female 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. 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 Dufferin & District, 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 the Agency is under no obligation to provide my child with a Mentor and that this application is the property of the Agency. I also agree that my child will participate in the Pre- Match Training Program administered by the Agency and the Upper Grand District School Board. I understand that, if at home learning is happening, as the parent/guardian, I am responsible to supervise the virtual, phone or email contact between the Mentor and my child. I understand that the mentoring relationship is the solely between the agency, my child and myself as the parent/guardian. The Upper Grand District School Board is not responsible for supervision of my child during meetings with the Big Brothers Big Sisters’ Mentor (whether my child is in-school or at home) nor the content of the Big Brothers, Big Sisters In-School Mentoring Program. Inherent risks include, but are not limited to, eye and hand strain, muscle and joint problems, headaches, inappropriate content, inappropriate use of technology, cyberattacks, breach of confidentiality or sensitive information. The Upper Grand District School Board and/or Big Brothers Big Sisters do not provide medical insurance or cyber liability insurance coverage for students.(Required) I, the parent/guardian hereby request Big Brothers Big Sisters service for my child. I give the agency and the Upper Grand District School Board 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. Parent/Guardian Signature(Required)Optional Section: Statistical InformationAt 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 directlyPrefer not to answerArab/Western Asia (e.g., Egypt, Syria, Jordan, Lebanon, Saudi Arabia, UAE, Turkey, Armenia, Georgia, Israel, Palestine, etc.)Black/African Descent (Black (African Descent), Afro-Caribbean, African-Canadian Descent)CanadianCentral Asian (e.g., Tajikistan, Uzbekistan, Kazakhstan, Turkmenistan, Kyrgyzstan)East/Southeast Asian (e.g., China, Japan, Korea, Mongolia, Taiwan, Philippines, Vietnam, Cambodia, Thailand, Malaysia, etc.)European Descent (Western European countries like England, Germany, France, Italy, etc.) (Eastern European e.g., Croatia, Serbia, Czech Republic, Slovakia, Hungary, Ukraine, etc.)French CanadianIndigenous Peoples (First Nations, Métis, Inuit, etc.)JewishSouth Asian (e.g., Sri Lanka, Bangladesh, India, Afghanistan, Pakistan, Bhutan, Nepal, Maldives, Iran)If none of the options above accurately reflect your child's identity, please feel free to add a note here: PhoneThis field is for validation purposes and should be left unchanged. bigbrosbigsisofdufferin
