In-School Mentoring Consents Step 1 of 4 25% The In-School Mentoring Program is an exciting mentoring program currently offered through Big Brothers Big Sisters of London and Area for children in grades 1-8. The goal of the In-School Mentoring Program is to provide students with a special one-to-one friendship with a mentor. Our mentors are volunteers from Big Brothers Big Sisters of London and Area who undergo an extensive screening and training process prior to being placed at your child’s school. Your child will be matched with one mentor until the end of April or June. Your child’s mentor will visit the school once a week over the nutritional break and engage in activities that meet the interests of your child. Such activities may include: board games, arts and crafts, reading, gym/outdoor activities, etc. All activities are geared toward developing the strengths of your child and are meant to be fun and educational! A match meet will take place with an agency staff to introduce the mentor to your child at the school. We encourage and invite you to attend this meet if possible, once scheduled. The activities are up to your child and the mentor to decide, but always take into consideration safety and will always be on school property. Your child’s mentor has been made very aware that there is to be no communication with your child outside of school hours. If you have further questions, please do not hesitate to contact Big Brothers Big Sisters of London and Area. This field is hidden when viewing the formIn-School MentoringThe In-School Mentoring Program is an exciting mentoring program currently offered through Big Brothers Big Sisters of London and Area for children in grades 1-8. The goal of the In-School Mentoring Program is to provide students with a special one-to-one friendship with a mentor. Our mentors are volunteers from Big Brothers Big Sisters of London and Area who undergo an extensive screening and training process prior to being placed at your child’s school. Your child will be matched with one mentor until the end of April or June. Your child’s mentor will visit the school once a week over the nutritional break and engage in activities that meet the interests of your child. Such activities may include: board games, arts and crafts, reading, gym/outdoor activities, etc. All activities are geared toward developing the strengths of your child and are meant to be fun and educational! Regular school attendance is essential for the success of the mentoring relationship. A match meet will take place with an agency staff to introduce the mentor to your child at the school. We encourage and invite you to attend this meet if possible, once scheduled. The activities are up to your child and the mentor to decide, but always take into consideration safety and will always be on school property. In accordance to our program rules, contact between your child and their mentor is not permitted outside of their weekly meetings. If you have further questions, please do not hesitate to contact Big Brothers Big Sisters of London and Area. Please note that a witness is required to provide a signature before you are able submit these forms. please ensure you have a witness present as you are not able to save the document partially completed.In-School Mentoring Program – Mentee ApplicationIf your child is already matched with a Big Brother/Sister in our Community-Based program, they are not eligible for an In-School Mentoring match.Child's Full Legal Name(Required)Child's Preferred NameGender(Required)PronounsDate of Birth(Required) MM slash DD slash YYYY Ethnicity (We ask about ethnicity to support cultural understanding. Leave blank if you prefer not to share)Immigrant(Required) Yes No Grade(Required)School(Required)Parent/Legal Guardian’s Name(Required)Relationship(Required)Email(Required) Address(Required) Street Address Address Line 2 City Province Postal Code Phone number we can reach you at during the day(Required)Phone number type Home Work Mobile GETTING TO KNOW YOUR CHILDThis information will help us begin to understand and get to know your child.Does your child want a mentor?(Required) Yes No Why does your child want a mentor?(Required)Tell us about your child.(Required)Does your child have any specific medical conditions, allergies, or behaviours we should know about? If yes, please describe:(Required)Does anything prevent your child from fully participating in a mentoring relationship? If yes, please explain.(Required)Describe your child’s personality (please check any that best describes your child):(Required) Outgoing Active Passive Confident Determined Friendly Talkative Shy/Withdrawn Independent Helpful Any other words to describe your child’s personalityPlease check any of the following that describes your child’s interests:(Required) Cooking/Baking Music Board/Card Games Building/Lego Play Doh/Slime Arts and Crafts Reading Books Talking Computers Sports If your child is interested in sports, please specify.Is there anything you would like us to be aware of that would assist us in finding the right mentor for your child? If yes, please describe:(Required)Although you do not have to be involved in any particular way, the following options are available to you: Your child will meet their mentor during the school day. If possible, would you like to be present when they meet the first time? Every child in the program participates in pre-match training. Would you like to receive a copy of the material prior to your child participating? Would you like to receive updates about the mentoring relationship? Parent / Legal Guardian Signature(Required)Date(Required) MM slash DD slash YYYY Informed Consent (Site Based - 1:1 program) - ParentThis field is hidden when viewing the formConsent(Required)I hereby make formal application to Big Brothers Big Sisters of London and Area 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. In consideration for this service and other valuable consideration provided to my child by Big Brothers Big Sisters of London and Area, 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 London and Area, 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 Big Brothers Big Sisters of London and Area. I also agree that my child will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of London and Area. I agree to the privacy policy.I hereby make formal application to Big Brothers Big Sisters of London and Area 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.In consideration for this service and other valuable consideration provided to my child by Big Brothers Big Sisters of London and Area, 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 London and Area, 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 Big Brothers Big Sisters of London and Area. I also agree that my child will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of London and Area.I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT:(Required) I, the parent/guardian of the child named below hereby request Big Brothers Big Sisters service for my child. I give the agency 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.Child's Name(Required) First Last Parent Guardian Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY Media Consent Form – Child/YouthEnrolled at Big Brothers Big Sisters of London and AreaName of Child / Youth(Required) First Last Consent I hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters of London and Area the use of any photographs, audio and/or video recordings of my child or youth as taken or produced by media personnel and/or National Office or Local Agency staff at recreational events or match outings, or otherwise authorized by the National President & CEO, local agency President/Executive Director/CEO or Board of Directors, and that this media may be used by Local Agency and/or by the National Office for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the local agency websites and social media). Photographs or video productions may also be shared with community and school partners for program promotion.Name of Parent Guardian First Last SignatureDate MM slash DD slash YYYY Note: Confidentiality concern Please check here if you do not want your picture or your child’s picture used or if you have a safety concern.Parent / Guardian Name First Last SignatureDate MM slash DD slash YYYY Note: It is the parent/guardian’s responsibility to notify the office if the status of this consent changes.This field is hidden when viewing the formNote: It is the parent/guardian’s responsibility to notify the office if the status of this consent changes.First Choice Informed Consent to Survey – Parent/GuardianThis field is hidden when viewing the formInvestigator: Big Brothers Big Sisters of London and Area, (519) 438-7065 Purpose: I understand that the purpose of this data collection is to examine the benefits of being enrolled in BBBSOLA services on specific youth development areas (social skills, problem solving, and self-esteem for example) for youth engaged in our services, as well as to determine areas within the customer service of our organization that need improvement. Duration and Location: I understand that my child and I will be offered participation in voluntary surveys throughout the course of receiving services from BBBSOLA. These surveys may take from 5-15 minutes depending on the program and the individual. Procedures: My child and I will be asked to answer questions about our social and psychological well-being, as well as questions about our feelings and opinions on the services that we have received from BBBSOLA. Risks/Discomforts: It has been explained to me that some of the interview questions may be considered somewhat personal and may cause some slight discomfort in answering them. Benefits: I understand that the benefits from participating in this study may be to help BBBSOLA, and perhaps Big Brothers Big Sisters chapters across Canada, better understand the benefits of receiving BBBSOLA services, as well as the areas in which these services can improve. Confidentiality: I understand that a research code number will be used to identify my and my child’s responses from those of other clients and that our name, address, and other identifying information will not be directly associated with any information obtained from us. A master listing of persons participating in the study will be kept in a database in a secure location, password protected, under lock and key, and only accessible by select staff. When results of this data collection are published or reported, our names or other identifying information will not be used. Right to Stop or End Participation: I understand that my child and I do not have to take part in this data collection or complete any survey offered to us by BBBSOLA staff and that our refusal will not involve any penalty or loss of rights, nor will it affect the service that we receive from BBBSOLA in any way.First ChoiceSecond ChoiceThird ChoiceInvestigator: Big Brothers Big Sisters of London and Area, (519) 438-7065Purpose: I understand that the purpose of this data collection is to examine the benefits of being enrolled in BBBSOLA services on specific youth development areas (social skills, problem solving, and self-esteem for example) for youth engaged in our services, as well as to determine areas within the customer service of our organization that need improvement.Duration and Location: I understand that my child and I will be offered participation in voluntary surveys throughout the course of receiving services from BBBSOLA. These surveys may take from 5-15 minutes depending on the program and the individual.Procedures: My child and I will be asked to answer questions about our social and psychological well-being, as well as questions about our feelings and opinions on the services that we have received from BBBSOLA.Risks/Discomforts: It has been explained to me that some of the interview questions may be considered somewhat personal and may cause some slight discomfort in answering them.Benefits: I understand that the benefits from participating in this study may be to help BBBSOLA, and perhaps Big Brothers Big Sisters chapters across Canada, better understand the benefits of receiving BBBSOLA services, as well as the areas in which these services can improve.Confidentiality: I understand that a research code number will be used to identify my and my child’s responses from those of other clients and that our name, address, and other identifying information will not be directly associated with any information obtained from us. A master listing of persons participating in the study will be kept in a database in a secure location, password protected, under lock and key, and only accessible by select staff. When results of this data collection are published or reported, our names or other identifying information will not be used.Right to Stop or End Participation: I understand that my child and I do not have to take part in this data collection or complete any survey offered to us by BBBSOLA staff and that our refusal will not involve any penalty or loss of rights, nor will it affect the service that we receive from BBBSOLA in any way.Consent I have read this entire consent form and completely understand my rights with regard to collection of data from BBBSOLA. I voluntarily consent to participate in this research. I have been informed that I will receive a copy of this consent should questions arise.Signature of Parent/Guardian(Required)Name of Parent/Guardian(Required) First Last Date(Required) MM slash DD slash YYYY Signature of Witness(Required)Name of Witness(Required) First Last Date(Required) MM slash DD slash YYYY Share: Facebook Google+ LinkedIn
