Site Based Group Program: Mentoring with Math - Child Application Form Step 1 of 8 12% What day would you like to enroll your child in?*Surrey Strawberry Hill Library (In-person, Tuesdays): Jan 17, 2023 -March 7, 2023 (4pm to 5:30pm)Virtual sessions (On Zoom, Mondays): Jan 16, 2023 -March 6, 2023 (4pm to 5pm)Virtual sessions (On Zoom, Tuesdays): Jan 17, 2023 -March 7, 2023 (4pm to 5pm)Virtual sessions (On Zoom, Wednesdays): Jan 18, 2023 -March 8, 2023 (4pm to 5pm)Once date & time for each program are confirmed, we will contact you. Your Child InformationFull 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 InfomationFull Name of Parent/Guardian* Relationship to the child* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Address* Enter Email Confirm Email Home Phone*Cell Phone*OPTIONAL - Work Phone Save and Continue Later What is your child’s grade level in math?** This program is intended to support children struggling with math concepts at or below their grade level. How would your child benefit from the Math & Mentoring Program?*Besides math, are there other challenges your child faces?*We provide a small healthy snack to children in our after school programs. Does your child have any specific medical conditions, dietary restrictions, allergies or other concerns we should know about? Please describe*Where did you hear about the program?*Is there anything else you would like to share with us or that may be important for us to know?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 Save and Continue Later Emergency ContactPlease 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* Relationship to Child* Home Phone*Cell Phone* Save and Continue Later Absent Child Policy*Parents/guardians are responsible for informing the Mentoring Coordinator if their child will be absent from the program. I have read, understand, and accept the Absent Child Policy. Save and Continue Later AUTHORIZED PICK-UP INFORMATIONThe 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 PhoneCell Phone Save and Continue Later 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. Save and Continue Later MEDIA CONSENTAny 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 Save and Continue Later 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* Save and Continue Later 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.