Community Mentoring Online Application

Dear Parent(s)/Guardian(s),

The Community Mentoring Program matches children/youth (aka a “mentee”) aged 6-16, to an adult mentor aged 19 years or older. Matches spend one-to-one time together for 2-4 hours per week for a minimum of a year. Matches can participate in variety of mutually-agreed-upon activities such as arts & crafts, puzzles, sports, reading, games, board games, outside activities, etc.

Mentors in this program have been screened, interviewed, trained and have completed a criminal record check including a vulnerable sector check. This experience is meant to provide children/youth with a positive mentoring relationship that they can look forward to each week, learning new things while increasing self-confidence. All children/youth participating in this program must attend a Child Safety Program – Strong from the Start. If your child/youth is matched in this program, we ask that you talk to your child about the activities they participate in with their mentor to ensure they feel comfortable at all times. We invite you to complete and submit the application, and consent and release form below in order to facilitate your child being matched in the Community Mentoring Program.

Big Brothers Big Sisters of Central Vancouver Island is committed to providing a positive mentoring experience for your child. If you have any questions or concerns at any time, please call 250-756-2447.

Community Mentoring Application Form

Child/Youth's Name*
First Middle Last
Child/Youth's Gender*
- Female
- Male
Child/Youth's Pronoun*
Child/Youth's Date of Birth*
Month
Day
Year
Child/Youth's Current School*
Current Teacher's Name*
Current Grade*
Child/Youth's Ethnic background
Response to this question is voluntary. Information will be used for statistical purposes only.
- Aboriginal (Indigenous)
- English Canadian
- French Canadian
- Middle Eastern / West Central Asian
- East or Southeast Asian
- Central or South American
- Caribbean
- South Asian
- European
- African
- Other
Participant's Parent/Guardian:*
- I represent that I have legal capacity and authorization to act on behalf of the Participant.
Name of Primary Parent/Guardian*
First Last
Parent/Guardian Phone*
At what phone number can we reach you during the day?
Parent/Guardian Email*
Address*
Street Address Address Line 2 City Province Postal Code
Where did you hear about or were referred to the program (your child's school, word of mouth, through a friend, etc.)?*
Why do you feel your child/youth would benefit from having a Big Brother/Sister in their lives?*
Please provide details on others living in the home (other siblings, their ages, gender, relationships; step-family members,etc.)
Does your child have any specific medical conditions, allergies or other concerns we should know about? If yes, please describe:
Please provide details.
Is the Child/Youth taking any medication?*
- Yes
- No
If yes, please specify:
Does your child/youth want a mentor?*
- Yes
- No
- Not Sure
Why does your child/youth want a mentor?
Has your child seen or are they currently seeing a psychologist, social worker, therapist counsellor, etc.?*
- Yes
- No
If so, please explain (if applicable include approximate dates as well as the name, address and phone number of the worker?
Does your child/youth have any diagnosed learning or behavioural challenges?
Is there anything you would like us to be aware of that would assist us in finding the right mentor for your child/youth?
Please check any of the following that describes your child’s interests:
- Animals
- Cooking
- Educational Activities
- Music
- Talking
- Arts & Crafts
- Computers
- Festivals and Local Events
- Outdoor Activities
- Video Games
- Building (Lego)
- Cultural Activities
- Indoor Activities
- Reading/Books
- Board Games / Cards
- Dance
- Movies / T.V.
- Sports
Please check the character traits that best describe your child/youth
This information will help our group facilitators best support your child.
- Highly Active
- Friendly
- Outgoing
- Helpful
- Quiet
- Shy
- Withdrawn
Please check all categories that apply to your child/youth
- Frequent tardiness/absences
- Gives up easily
- Difficult to engage
- Struggling academically
- Attention difficulties (please specify in comment box below)
- Learning disorders (please specify in comment box below)
- Loneliness / social isolation
- Difficulty relating to peers
- English as a second language
- Dealing with anger issues
- Low self-esteem
- Bullies other children
- Is being bullied
Your Involvement
Although you do not have to be involved in any particular way, the following options are available to you:
- 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?
- If you would like to be involved in some other way, please contact the Big Brothers Big Sisters office.
Informed Consent and Confidentiality
Informed Consent*
I hereby make formal application to Big Brothers Big Sisters of Central Vancouver Island to make available their service to my child. It is my understanding that the intention of the Agency is to match my child, in an individual or group program, with a responsible 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 Central Vancouver Island, 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 Central Vancouver Island 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 Central Vancouver Island. I also agree that my child will participate in the Pre-Match Training Program administered by Big Brothers Big Sisters of Central Vancouver Island.

I HAVE READ AND UNDERSTAND THIS AGREEMENT. I ACKNOWLEDGE THAT I, the parent/guardian, 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.
Confidentiality Agreement*
All staff and volunteers of Big Brothers Big Sisters of Central Vancouver Island (the “Agency”) are required to abide by this Confidentiality Policy. Any breach of this policy will be considered grounds for termination.

Agency Service Delivery Staff will explain the confidential nature of our service to the volunteer, child and parent/guardian as early as possible in the orientation and/or screening process. At all times thereafter Service Delivery Staff will ensure the privacy of case information.
Information contained in the Casework files will not be disclosed by the Agency to any person without written approval of said person except in the following cases:
1. 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. This could result in the disclosure of confidential information without written consent from the person to Brothers Big Sisters of Canada’s insurers and or legal counsel, as may be appropriate in connection with any legal proceeding or inquiry;
2. When subpoenaed by the courts;
3. Where required by law; and
4. During periodic agency accreditation reviews; case records, including relevant personal information will be shared to authorized representatives of Big Brothers Big Sisters of Canada.
In the event that confidential information is requested to support a custody or access application, or for any court matter other than a “child protection” case, the Agency 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.

Case records will be accessible only to the Caseworker, Executive Director, Casework Supervisor, and in appropriate situations, other Caseworkers.

I understand the Agency’s policy around confidentiality and have read and agree to all the terms and conditions
ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT
ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT - CONSENT
The information being collected by the Agency is being collected for the express purpose of operating the mentorship program and will be used and may be disclosed to staff and volunteers as required for such purpose.
ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT*
By signing this Assumption of Risk, Release and Indemnity Agreement, you (on behalf of a mentee (the “Participant”), if applicable) are waiving important legal rights, including the right to sue. Please read carefully. This agreement must be completed in full before you (or the Participant, as applicable) can take part in any further in-person meetings with mentors that are authorized by Big Brothers Big Sisters of Central Vancouver Island (respectively, “Meetings”, “Mentors”, and the “Agency”).

Therefore, in consideration of the Participant participating in any further Meetings and for other good and valuable consideration (the receipt and sufficiency of which are hereby acknowledged by the Undersigned), the Undersigned hereby:

1. Freely ASSUMES ALL RISK in respect of the Participant’s participation in the Program;

2. RELEASES AND FOREVER DISCHARGES the Agency and all of its predecessor, subsidiary, parent, related, affiliated and successor companies, including but not limited to Big Brothers Big Sisters of Canada (collectively, the “Organizations”) and all of their respective present and former officers, directors, employees, volunteers (including Mentors), representatives and agents of the Companies (collectively, the “Released Individuals”) (the Organizations and the Released Individuals are collectively referred to as the “Released Parties”) from any and all responsibility, liability, cause of action or claim of any kind whatsoever in respect of the Participant’s participation in the program due to any cause whatsoever including negligence or breach of any other duty of care on the part of the Agency or the Participant’s Mentor and including the failure of the Agency or the Participant’s Mentor to safeguard or protect the Participant from the risks, dangers and hazards associated with the program;

3. INDEMNIFIES all of the Released Parties from and against any and all liability incurred by any or all of them as a result of, or in any way connected with the Program; and

4. Agrees that the provisions of this agreement shall enure to the benefit of the respective successors and assigns of the Agency and the Participant’s Mentor and shall be binding upon the Undersigned’s heirs, next of kin, executors, administrators and personal representatives.

I HAVE CAREFULLY READ THIS AGREEMENT IN ITS ENTIRETY AND UNDERSTAND ITS CONTENT. I AM AWARE THIS IS AN ASSUMPTION OF RISK, RELEASE AND INDEMNITY AND I SIGN IT VOLUNTARILY.
MEDIA CONSENT
Media Consent*
I hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters of Central Vancouver Island 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. Note: It is the parent/guardian’s responsibility to notify the office if the status of this consent changes.
- YES
- NO
Program Application*
I am the legal guardian of the applicant and by submitting my name below I am acknowledging that the information contained in this online form is true and accurate to the best of my knowledge. I also understand and agree to all of the terms and conditions contained in this form.
Parent or Guardian's Name*
First Middle Last
Date*
MM slash DD slash YYYY

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Community Mentoring Online Application

Community Mentoring Application Form

Informed Consent and Confidentiality

ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT

ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT - CONSENT

MEDIA CONSENT