Mentoring with Math - Child Application Form - Big Brothers of Greater Vancouver

Site Based Group Program: Mentoring with Math - Child Application Form

* 2022 FALL SCHEDULE *

Surrey at Strawberry Hill Library (In-person) - TUESDAYS 4pm -5:30pm from October 11, 2022 to December 13, 2022
Surrey at Newton Elementary School (In-person) - WEDNESDAYS 4pm -5:30pm from October 12, 2022 to December 14, 2022
Burnaby at Edmonds Community School (In-person) - THURSDAYS 2:30pm -4pm from October 20, 2022 to December 15, 2022
Virtual sessions on Zoom - TUESDAYS 4pm -5pm from October 11, 2022 to December 13, 2022
Virtual sessions on Zoom - WEDNESDAYS 4pm -5pm from October 12, 2022 to December 14, 2022

Step 1 of 8

Thank you for your interest in signing up your child(ren) in the Mentoring with Math program.
What day would you like to enroll your child in?*
Your Child Information
Full Name of Child*
First Last
Gender identity of the child*
Birthdate*
MM slash DD slash YYYY
What grade is your child currently in?*
What school is your child enrolled in?*
Parent/Guardian Infomation
Full Name of Parent/Guardian*
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

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AUTHORIZED PICK-UP INFORMATION
The following is required to ensure your child safety. Please choose one of the following:*

My child is allowed to walk home on their own

MY child is NOT allowed to walk home on their own. They will be picked up from the after school program by their parent(s)/guardian(s) or other authorized person(s).
Authorized Pick-Up*
I give permission to the following individual(s) to pick up my child from the Big Brothers of Greater Vancouver mentoring program. I have informed these individual(s) of the pick-up policy (see next page) and that they must present government-issued photo ID in order for my child to be released.

Your child(ren) 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.
I have read, understand, and accept the above agreement.
Authorized pick-up person #1*
Full Name

Relationship to Child*

Home Phone*
Cell Phone*
Authorized pick-up person #2 (Optional)
Full Name

Relationship to Child

Home Phone
Cell Phone

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Pick-Up Policy*
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. 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. 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. Consistent late pick-ups may result in the child being withdrawn from the program.
I have read, understand, and accept the Pick-Up Policy.

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MEDIA CONSENT
Any photographs, screenshots 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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INFORMED CONSENT (SITE-BASED)*
I hereby make formal application to Big Brothers of Greater Vancouver to make available their service to my child. The service programs may take the form of in-person or virtual programming between a volunteer and my child, and is supported by Big Brothers of Greater Vancouver staff. It is my understanding that the intention of the Agency is to match 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 on site or virtually. 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 of Greater Vancouver, 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 of Greater Vancouver, 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 of Greater Vancouver. I also agree that my child will participate in the Pre-Match Training Program administered by Big Brothers of Greater Vancouver.
I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT: I hereby request Big Brothers Big Sisters services 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.
Signed on (Date)*
MM slash DD slash YYYY

Full Name of Parent/Guardian*

Parent/Guardian Signature*

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For more information about enrolling your child in this program, please contact Loreen Kishor, Group Program Manager at Loreen.Kishor@bigbrothersbigsisters.ca, or via phone at 604-499-2336.

Mentoring with Math – Child Application Form

Site Based Group Program: Mentoring with Math - Child Application Form

Step 1 of 8

Your Child Information

Parent/Guardian Infomation

Emergency Contact

AUTHORIZED PICK-UP INFORMATION

MEDIA CONSENT

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