In-School Mentoring Application Form

Dear Parents/Guardians,

The In-School Mentoring Program matches a child/youth from grades K-7 (aka a “Little”) with an adult (aka a “Big”) or teen mentor student (grades 10-12). Matches spend one-to-one time for an hour, at a predetermined day of the week throughout the duration of the school year. The mentors will not have contact with children/youth outside of school hours. Matches participate in a variety of mutually-agreed-upon activities such as arts & crafts, puzzles, sports, reading, games, board games, etc. This experience is aimed to provide children/youth with a positive mentor relationship that they can look forward to each week, learning new things, and increasing self-confidence.

Due to the current pandemic, match meetings will be conducted virtually (via Zoom, or via the Mentor-to-Go app, to be launched in early 2021). All mentors in this program have been screened, interviewed, trained and have completed a criminal record check including a vulnerable sector check.

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, & consent and release form below in order to facilitate your child being matched in the In-School Mentoring Program. Once complete, a referral form filled out by a parent, teacher, counsellor, or school liaison, will be provided to Big Brothers Big Sisters to best match your child/youth.

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

PLEASE NOTE: This information will be updated regularly to reflect any and all Public Health Orders surrounding Covid-19.

  • Response to this question is voluntary. Information will be used for statistical purposes only.
  • At what phone number can we reach you during the day?
  • Please provide details.
  • This information will help our group facilitators best support your child.
  • Although you do not have to be involved in any particular way, the following options are available to you:
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  • INFORMED CONSENT

  • MM slash DD slash YYYY
  • ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT

  • Child/Youth
  • MM slash DD slash YYYY
  • 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.
  • 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.