Game On - Child Application Form - Big Brothers of Greater Vancouver

Game On! - Child Application Form

If you are interested in registering a child for the Game On! program virtually or in-person this 2020-2021 school year, please fill out the following form. An electronic waiver will be sent to the Parent/Guardian upon submission, and this waiver must be returned to Big Brothers of Greater Vancouver staff prior to the student participating in our programs. During the COVID-19 pandemic, an additional participatory waiver must also be signed. These waivers will be sent to the e-mail address provided.

Step 1 of 3

Which site would you like to enroll your child?*
Child Name*
First Last
Birthdate*
MM slash DD slash YYYY
Gender identity of the child*
Parent/Guardian's full name*
Relationship to the child?*
Address*
Street Address Address Line 2 City Province Postal Code
Email Address*
Enter Email Confirm Email
Home Phone*
Cell Phone*
OPTIONAL - Work Phone
Emergency Contact
Please ensure this person is someone other than the parent/guardian, and they must have a phone number that is different from the parent/guardian.
Emergency Contact's Full Name*
Address*
Street Address Address Line 2 City Province Postal Code
Relationship to Child*
Home Phone*
Cell Phone*

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What school is your child enrolled in?*
What grade is your child currently in?*
Please list at least four of your child's interests and favourite activities to help us match your child to a Mentor who shares similar interests.*
Where did you hear about the program?*
The following optional information is asked for statistical purposes and for grant/funding support. The questions and responses do not indicate or affect participation requirements.
OPTIONAL - What ethnicity is your child?
OPTIONAL - Was your child born in Canada?
If not, how long as your child lived in Canada?
Languages Spoken
Is there anything else you would like to share with us or that may be important for us to know?

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Authorized Pick-Up Form
I, (parent/guardian), give permission to the following individuals to pick up my child from the Big Brothers of Greater Vancouver mentoring program. I have informed these individuals of the pick-up policy (see below) and that they must present government-issued photo ID in order for my child to be released. Your children will not be allowed to leave the site with anyone other than those listed below. You can remove or add people to this list at any time by contacting your Mentoring Coordinator and signing an updated Authorized Pick-Up Form.
Please check if you have read, understand, and accept the above Agreement*
- Yes
Authorized pick-up person #1*
First Last
Relationship to your child*
Phone number*
Alternative phone number
Authorized pick-up person #2 (optional)
First Last
Relationship to your child
Phone number
Alternative phone number
Absent Child Policy
Parents/guardians are responsible for informing the Mentoring Coordinator if their child will be absent from the program.
Please check if you have read, understand, and accept the above Agreement*
- Yes
Pick-Up Policy
a) Parents/guardians or authorized pick-up person must pick up their child at the program end time. Your program information will be given to you by your Mentoring Coordinator.

b) The Mentoring Coordinator will call the guardian and/or authorized pick-up person if the child was not picked up within 10 minutes of the program ending.

c) If the guardian and/or authorized pick-up person is unreachable, the Mentoring Coordinator will call the emergency contact within 20 minutes of program ending.

d) The Mentoring Coordinator will call MCFD or the local police if there is no contact with the guardian or emergency contact within 30 minutes of program ending.

e) Consistent late pick-ups may result in the child being withdrawn from the program.
Please check if you have read, understand, and accept the above Agreement*
- Yes
Media Consent
Any photographs or video productions taken of my child by agency staff at the mentoring program may be used by the agency for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions, and web pages, such as agency website and social media, and grant proposals/reports. Photographs or video productions may also be shared with community and school partners for program promotion.

Your response to this question, either way, does not affect your eligibility to the program.
Please check only one of the two options below:
- I agree with the Media Consent release above
- I do not agree with the Media Consent release above

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In Vancouver and Surrey:

Mentoring Coordinator, Ray Khan at 604- 764-8535 or rayhaan.khan@bigbrothersbigsisters.ca

Game On – Child Application Form

Game On! - Child Application Form

Step 1 of 3

Emergency Contact

Authorized Pick-Up Form

Absent Child Policy

Pick-Up Policy

Media Consent

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