Summer Program Application Form - Big Brothers Big Sisters of London and Area

Child's Preferred Name

Date of Birth

Gender

Pronouns

Ethnicity (only if you want to share)

Grade (2024-25)

Email

Phone

Does your child have any allergies and/or medical protocols we need to be aware of? (i.e. Epi-pen, Benadryl)

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:

Relationship to Child

Emergency Contact Phone

Signature of Parent/Guardian

Date

Confidentiality Policy and Consent to Exchange Information

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Information held by Big Brothers Big Sisters of London and Area (BBBSOLA) will not be disclosed to any person without written approval of said person except in the following cases:  Where the safety of a child depends upon divulging this information. This could include suspicion of neglect or abuse of a child. The proper authorities will be informed when necessary, which could result in the disclosure of confidential information without written consent from the person;  When subpoenaed by the courts;  Where required by law. In the event that confidential information is requested to support custody or access application, or for any court matter other than a “child protection” case, BBBSOLA will only release the information if required to do so by a Judge’s Order. No staff member or volunteer shall use confidential information from the agency to advance any personal interest, financial or otherwise. In accordance with Big Brothers Big Sisters of Canada’s National Standards:  No information will be provided to persons or organizations outside of Big Brothers Big Sisters of Canada, and its agents, about parents, children or volunteers without their express prior written consent except where required by law.  All information and records, including electronic records, shall be kept secure (for example, in a filing cabinet, desk, etc. under lock and key, password protected, etc.) and confidential at all times. I understand that BBBSOLA may need to exchange information with others so that the Agency can understand my needs and serve to meet those needs. I hereby consent to the exchange of information, at the discretion of BBBSOLA, with my mentor throughout the matching process, as well as for the purpose of match supervision throughout my mentoring relationship. I hereby consent to any exchange of information deemed appropriate regarding myself between Big Brothers Big Sisters of London and Area and:

Information held by Big Brothers Big Sisters of London and Area (BBBSOLA) will not be disclosed to any person without written approval of said person except in the following cases:

-Where the safety of a child depends upon divulging this information. This could include suspicion of neglect or abuse of a child. The proper authorities will be informed when necessary, which could result in the disclosure of confidential information without written consent from the person; when subpoenaed by the courts; where required by law.

In the event that confidential information is requested to support custody or access application, or for any court matter other than a “child protection” case, BBBSOLA will only release the information if required to do so by a Judge’s Order.

No staff member or volunteer shall use confidential information from the agency to advance any personal interest, financial or otherwise.

In accordance with Big Brothers Big Sisters of Canada’s National Standards: -No information will be provided to persons or organizations outside of Big Brothers Big Sisters of Canada, and its agents, about parents, children or volunteers without their express prior written consent except where required by law. -All information and records, including electronic records, shall be kept secure (for example, in a filing cabinet, desk, etc. under lock and key, password protected, etc.) and confidential at all times.

I understand that BBBSOLA may need to exchange information with others so that the Agency can understand my needs and serve to meet those needs.

I hereby consent to the exchange of information, at the discretion of BBBSOLA, with my mentor throughout the matching process, as well as for the purpose of match supervision throughout my mentoring relationship.

I hereby consent to any exchange of information deemed appropriate regarding myself between Big Brothers Big Sisters of London and Area and:

Signature

Date

Informed Consent (Site Based group program) - Parent

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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, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. 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- 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: I, the parent/guardian of the child named 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 hereby consent to allowing my child to leave the program at any time without supervision. I acknowledge and accept the risks associated with my child leaving the program unsupervised.

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, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program.

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- 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: I, the parent/guardian of the child named 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 hereby consent to allowing my child to leave the program at any time without supervision. I acknowledge and accept the risks associated with my child leaving the program unsupervised.

Signature

Date

Media Consent Form – Summer Programming

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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.

Name of Agency: Big Brothers Big Sisters of London and Area

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.

Parent/Guardian Signature

Date

Note: Confidentiality concern

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

Parent/Guardian Signature

Date