Youth Enrollment Application - Big Brothers Big Sisters of the Capital Region

Youth Application

Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.

Hidden Fields

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Youth Information

First Name

Middle Name

Last Name

Preferred Name

Birthdate

Enter a date in the following format: mm/dd/yyyy

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?
School	Graduation Year This is the year the youth will graduate.

School Account ID

Race/Ethnicity

American Indian or Alaska NativeAsian IndianBlack or African AmericanChamorroChineseFilipinoHispanic - CubanHispanic-Mexican,MexicanAmerican,ChicanoHispanic-Other Latinx or Spanish originHispanic - Puerto RicanJapaneseKoreanMiddle Eastern or North AfricanNative HawaiianOtherOther AsianOther Pacific IslanderPrefer not to saySamoanSome other race or originVietnameseWhite or Caucasian

Nationality/Country of Origin:

Primary language(s) spoken in the household:

No proficiencyElementaryLimited WorkingProfessional WorkingFull Native

Language:

Secondary language (s) spoken in the household:

No ProficiencyElementaryLimited workingProfessional workingFull native

Language:

Please note: At this time Big Brothers Big Sisters maintains the capacity to provide services to English speaking families and translating for Spanish speaking families. Please let us know if your family does not fall into this service area. If you are able to provide translation services, please let us know and provide the name/contact information for the translator.

Does the youth have their own phone?

YesNo

Is it okay to text youth?

YesNo

Youth's Phone Number

How would you describe the youth, in terms of participation in events, activities, or sports?

Which activities does the youth enjoy more?

Does your child have any medical conditions (including food allergies) that might affect them participating in activities with a Big?

Does the youth have any allergies?

YesNo

Allergies Description

Is the youth taking any medications?

YesNo

Medications Description

Pertinent Medical History

Does your child receive any of these services?

Special Education Speech therapyTutoringIn-school counseling

Is your child currently approved for and receiving OPWDD services?

YesNo

Please list services:

Has the youth ever been involved with the police or juvenile justice system?

What was their involvement?

Guardian's Relationship to Youth

Youth Living Situation

Living Situation Description

Is there a person who shares custody of this youth?

YesNo

Custody is shared with:

Does the youth have a parent/guardian who is currently incarcerated?

YesNo

Does the youth have a parent/guardian who is serving or served in the military?

Is the youth's parent/guardian currently deployed?

YesNo

If yes, please list dates of service:

Branch:

Air Force ArmyMarine CorpsNavyCoast Guard

Component

ActiveNational GuardReserve

Is the parent retired from the military?

YesNo

Is the parent separated/discharged (other than retired)?

YesNo

Does your child have a parent/caregiver that is considered fallen, wounded or disabled?

YesNo

Within the last year, has your child been in any trouble at school?

Poor Grades Skipping school/classes TruantBehavior problems Has been suspended Has been expelled Sent to an alternative school

Please Explain

Please Choose the Program You are Interested In

Community-Based Mentoring:

Adult volunteers and Littles spend time together in the community, building friendships and enjoying everyday fun and activities. All outings are done based on the volunteer, child and parent schedule. The volunteers provide transportation.

Site-Based Mentoring:

College aged volunteers and Littles spend time together on a college campus, building friendships and enjoying everyday fun and activities. Outings are always on Saturdays from 12 pm – 3 pm with transportation provided. The campus program does not meet during any school breaks or over the summer.

What strengths does your child have that a Big might be able to help grow?

What are some of the needs your child has (could be social, emotional, behavior, or academic) that a Big may be able to help them with?

How would you describe the best mentor for your child?

We will make every effort to honor your preferences for your child’s mentor. BBBS does not discriminate on the basis of race, ethnicity, gender, marital status, sexual orientation, or religion. [If applicable: BBBS also matches boys age 10 and under with female volunteers when there is a lack of male volunteers available].

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Mobile Phone

Home Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Work Email

Alternate Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

State

Zip Code

Annual Household Income

Is the youth eligible to receive free/reduced lunch?

YesNo

Does your family receive income assistance?

YesNo

Is parent/guardian receiving assistance with housing (i.e. Section 8, residence in public-housing, etc.)?

YesNo

Do you anticipate any significant life changes over the next year, or have you had any in the past year?

YesNo

Life Changes Description

How did you hear about Big Brothers Big Sisters?

Existing Household Members

Please choose this child's relationship to the following people:

Name:	Relationship:
App record ID	contact record ID

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Is the child fully vaccinated?

YesNo

Has the child received a booster shot?

YesNo

Confidentiality Policy

https://docs.google.com/document/d/1EIaztjvXn2DNzX-9YDO6mWqC6lb5ON0bSVxyn2Wg0yw/edit

I have read and understand the above information provided to me regarding Big Brothers Big Sisters Confidentiality Policy. I agree by the conditions set forth.

I consent to use images and consent to use my name in promotional materials for Big Brothers Big Sisters of the Capital RegionI do not consent

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

By signing below, I give permission:

For my child to participate in the Big Brothers Big Sisters Program;
For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);
To have my child participate in an enrollment interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests;
To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
For BBBS staff to provide contact information to the volunteer for the purpose of contacting my child.

I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I may be asked to provide additional information. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information shared in my child’s in-take interview).

I certify that all of the information on this form is true and correct and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my qualification for the program.

I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me as his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable.

If my child is matched with a Big Brother or Big Sister I agree to support my child’s match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff at least once per semester and once during summer break, and immediately reporting any concerns I might have to the school or Big Brothers Big Sisters staff.

I have read the above youth safety guidelines and ground rules which define my responsibilities as the parent/guardian of a Little. I agree to abide by them as long as my youth is in the program and I understand that BBBS has the right to close my youth’s match at any time.

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Contact Information