Roots Mentoring - Child Application Form

Roots - Child Application Form

At Big Brothers of Greater Vancouver, we embody the principles of diversity, equity and inclusion. Our families and volunteers represent a diversity of backgrounds, experiences, abilities, and identities. We welcome volunteers, children, and families of all sexual orientations, gender identities and expressions, including transgender and gender-fluid individuals.

Step 1 of 3

CHILD INFORMATION
Please choose your child's school from the list.*
- Lord Kelvin Elementary
- Lord Strathcona Elementary
- Beaver Creek Elementary
- K.B. Woodward Elementary
- Blundell Elementary
Full Name*
First Last
Birthdate*
Gender identity*
Grade*
Roots program is for children in grades 1 to 7
Optional questions

For statistical purposes and to support funding
Ethnicity
Language(s) Spoken
Was your child born in Canada
- Yes
- No
How long has the child lived in Canada
PARENT / GUARDIAN INFORMATION
Parent/Guardian Full Name*
Relationship to child*
Address*
Street Address City Postal Code
Email Address*
Enter Email Confirm Email
Do you have a cell phone?*
- Yes
- No
It is ok if you don't have a cell phone. We ask this question because we use a text message verification for your e-signature at the end of this form. We will connect with you with an alternative method.
Cell Phone Number*
Please have your cell phone with you. We use SMS verification at the last page and send a code to your phone for you to enter.
Home Phone if applicable
Work Phone (optional)
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.*
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?

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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 Full Name*
Relationship to Child*
Phone*
Alternative phone
AUTHORIZED PICK-UP INFORMATION
The following is required to ensure 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 and will be picked up by the Parent/Guardian or other authorized person(s).Second Choice
Authorized Pick-Up*
I give permission to the emergency contact and the following authorized 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.

I have read, understand, and accept the above agreement.
Authorized Pick-Up Person #1

Full Name
Relationship to child
Phone Number
Alternate Phone Number
Authorized Pick-Up Person #2 (Optional)

Full Name
Relationship to child
Phone Number
Alternate Phone Number
Authorized Pick-Up Person #3 (Optional)

Full Name
Relationship to child
Phone Number
Alternate Phone Number
Absent Child Policy*
Parent/Guardian is 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.
Pick-Up Policy*

Parent/guardian (P/G) or authorized pick-up persons must pick up the child at the program end time.

The Mentoring Coordinator will call the P/G and/or the authorized pick-up persons if the child was not picked up within 15 minutes of the program ending.

If the P/G and/or authorized pick-up persons is unreachable, the Mentoring Coordinator will call the emergency contact within 30 minutes of program ending.

In the event the Mentoring Coordinator is unable to reach the P/G, Emergency Contact or any of the authorized pick-up persons by 60 minutes of the program ending, the Mentoring Coordinator will need to contact local authorities* to ensure welfare of child and the P/G.

*At Big Brothers we recognize interactions with the police or child protection services have been harmful for individuals and communities, particularly marginalized communities. We will do our best to refrain from such interactions unless necessary, such as when we are unsuccessful in contacting the primary Parent/Guardian or any of the provided contacts 60 minutes after the program end. If you have concerns about this or would like to add additional authorized persons, please connect with your Mentoring Coordinator.

I have read, understand, and accept the Pick-Up Policy.

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Media Consent
Any photographs, screenshots, video recordings or 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.*
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

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.

Full Name*

SMS Verification*

Please enter your cell phone number and hit "Verify". You will receive a code via text to enter.

Signature of Parent/Guardian*
Signed on (date)*
MM slash DD slash YYYY

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Roots Mentoring – Child Application Form

Roots - Child Application Form

Step 1 of 3

CHILD INFORMATION

Optional questions

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACT

AUTHORIZED PICK-UP INFORMATION

Media Consent

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