Community Mentoring Application Form

  • 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:
  • MM slash DD slash YYYY
  • Informed Consent and Confidentiality

  • 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.

 

 

 

In-School Mentoring Application Form

  • 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:
  • MM slash DD slash YYYY
  • Confidentiality and 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.

 

 

 

Group Program Application Form

  • 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.
  • MM slash DD slash YYYY
  • Informed Consent

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

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