Pumped for Post Secondary Mentee Application

Mentee Application Form

Youth's Name(Required)

First Last

Youth's Preferred Name(Required)

Name

Youth's Gender(Required)

Youth's Pronouns

Youth's Address(Required)

Street Address Address Line 2 City Postal Code

Youth's Ethnicity(Required)

Immigrant(Required)

Yes

No

Youth's Grade (2025/2026)(Required)

Youth's Secondary School(Required)

Parent/Guardian's Name(Required)

First Last

Parent/Guardian's Email Address(Required)

Parent/Guardian's Phone Number(Required)

Allergies or Medical Conditions

Does your child have any allergies or medical conditions we need to be aware of (i.e. EpiPen)? Mentors and staff are only permitted to administer medication in the event of a life-threatening emergency. Administration of any other medication, including but not limited to Advil, Tylenol, or similar over the counter or prescription drugs, is strictly prohibited.

Physical or Mental Health Conditions

Does your child have any specific physical or mental health conditions we should know about? If yes, please describe and list any medications we should be aware of.

Emergency Contact (other than the parent/guardian above, and this person must be over the age of 18)(Required)

First Last

Emergency Contact – Relationship to Youth(Required)

Emergency Contact – Phone Number(Required)

Please acknowledge(Required)

I acknowledge that my child is responsible for their own transportation to and from the group program at Fanshawe’s main campus. My child is permitted to walk, take transit, or be picked up by a designated adult. I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area’s Privacy and Confidentiality Policy.

Parent/Guardian Signature(Required)

Date(Required)

Informed Consent (Pumped for Post-Secondary) – Parent/Guardian

I hereby give permission 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 offer my child an opportunity to participate in a group program lead by a responsible adult. 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 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 London and Area. I also agree that my child will participate in the Pre-Program 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 listed below, hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by Big Brothers Big Sisters of London and Area. 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. I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area’s Privacy and Confidentiality Policy.

Youth's Name(Required)

Parent/Guardian Signature(Required)

Date(Required)

Media Consent Form – Pumped for Post-Secondary

Check to consent(Required)

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 me 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. I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area’s Privacy and Confidentiality Policy.

Parent/Guardian Signature

Date

Note: Confidentiality Concern

Please check here if you do NOT want your picture used or if you have a safety concern

Parent/Guardian Signature

Date

Note: It is your responsibility to notify the office if the status of this consent changes.