Roots - Child Application Form CHILD INFORMATIONPlease choose your child's school from the list.* Lord Kelvin Elementary Lord Strathcona Elementary Beaver Creek Elementary K.B. Woodward Elementary Blundell Elementary Student Name* First Last Birthdate* MM slash DD slash YYYY Gender identity of the child* What grade is your child currently in?*Please enter a number from 0 to 7.For statistical purposes and to support funding Ethnicity (Optional) Language(s) Spoken (Optional) Was your child born in Canada (Optional) Yes No How long has your child lived in Canada (Optional) PARENT/GUARDIAN INFORMATIONFull 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 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? 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. Full Name of Emergency Contact* Relationship to Child* Phone*Alternative phone MEDIA CONSENT & INFORMED CONSENT 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 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. Date* MM slash DD slash YYYY Full Name of Parent/Guardian* Signature of Parent/Guardian*
