B You Online Program

REGISTRATION AND INFORMED CONSENT

Fill out the form below to register for the Spring 2023 session of B You Online. Spring 2023 sessions will begin the first week of May.

PLEASE NOTE GROUP START DATES ARE DEPENDENT ON REGISTRATION AND WILL BE CONFIRMED VIA EMAIL 1 WEEK IN ADVANCE.

B You Online Program Registration and Consent

Big Brothers Big Sisters of Victoria respects your privacy and adheres to British Columbia personal information privacy legislation (PIPA). The information provided will be used to create a confidential client file.

ABOUT B You Online
B You Online is a FREE 10-week online program designed for female identifying and gender-diverse youth between the ages of 11-15. The group meets weekly for 1 hour and 15 minutes via Zoom Online Platform. Groups will be a maximum of 12 mentees to 3 fully screened (Criminal Record Check included) and trained B You Facilitators. The focus of the program is to keep youth connected with each other and their community. They focus on building group connection by playing games, crafting, journaling and talking/discussions. This program is run by Big Brothers Big Sisters of Victoria Capital Region; an organization with 45 years experience of mentoring and creating a positive impact in the lives of children and youth.
Child/Youth Information
Child/Youth's Name*
First Last
Child/Youth's Birthdate*
MM slash DD slash YYYY
Child/Youth's Gender Identity*
- Female
- Male
- Transgender
- Non-Binary
- Other
Child/Youth Ethnic Identity
These responses are voluntary. Information provided will be used for statistical purposes only.
Was the child/youth born in Canada?
- Yes
- No
Does the child/youth have any dietary restrictions or allergies?
Please list below.
Child/Youth's Current Grade*
We will try our best to match your child/youth with other participants in the same grade.
Child/Youth's Current School*
If possible, we will try to match your child/youth with other participants who attend the same school.
Family/Youth Background Information
This section is used for statistical purposes only. Your answers will not not be shared, and they will not affect your child's application to the program.
Family Income Source
Select all that apply.
- Employed FT
- Employed PT
- Student
- EI / Social Assistance
- Disability
- Other
If you selected "Other" in the above question, please share here:
Family Income Level
- $0 - $30'000
- $30'001 - $50'000
- $50'001 - $75'000
- $75'001 and above
Family Type
Select all that apply.
- Single Parent (Female)
- Single Parent (Male)
- 2-Parent Blended
- 2-Parent Biological
- Adoptive Family
- Foster Family / Youth in Care
- Raised by Grandparent(s)
- Raised by Other(s)
- 1-2 Children
- 3-4 Children
- 5+ Children
Family Contact Information
Name of Primary Parent/Guardian*
First Last
Relation to Child/Youth*
Family Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Family Municipality/District Area*
I am the parent/guardian of the child for whom I am making this application.*
- Yes
- No
I am the emergency contact of the child for whom I am making this application.*
- Yes
- No
If you selected "No" in the above question, please insert the youth/child's emergency contact information here:
Emergency contact name, relationship to child, and phone number.
Family/Emergency Contact Phone Number
Required for emergency contact purposes.
Family Email*
This email will be used to communicate with the Parent/Guardian of the youth participating in B You Online.
Enter Email Confirm Email
Zoom Account Email (Used for Online Program)
This is the email the child/youth will use to join the online B You group via Zoom.
Enter Email Confirm Email
Scheduling Information
Has your child participated in the B You (formerly Go Girls) program before?*
- Yes
- No
- I'm not sure
Can you child/youth have independent access to Zoom?*
All B You Online sessions will take place virtually over Zoom video conferencing. In order to participate, your child will need private access to the Zoom app for each session, and a microphone/camera to participate with.
- Yes
- No
- Yes, but I may need help getting it set up
Which days of the week is your child/youth available to participate in B You Online?*
PLEASE SELECT MULTIPLE OPTIONS IF POSSIBLE | Intended start dates (subject to change): Early October
- Wednesday Evenings (6:30 PM - 7:45 PM)
- Thursday Evenings (6:30 PM - 7:45 PM)
How would you like to receive your B You Supply Kit?*
The online program includes a free supply kit for each child/youth participating in the 10 week program. There are two options; Pick up the kit from BBBS Office (230 Bay St - Vic West Area) on a designated date/time (TBA). Alternatively, I can supply you with a list if you want to purchase your own program supplies. If you cannot do either these options, please select "Other" and I will be in contact with you shortly to coordinate another plan. If you live in COMOX VALLEY there is another option to pick up your supply kit. If you live on Saltspring Island there is an option for you as well. If you live further, we can also work that out!
About the Child/Youth
Please note the following responses are voluntary and the information is used for statistical purposes only.
Does the child/youth have any diagnosed disorders/behavioural concerns/medical conditions we should know about?
Child is experiencing or has experienced:
Please check all risks/needs that apply to this child/youth. Please note that the following responses are voluntary and the information is used for statistical purposes only.
- Parental separation or divorce
- Loneliness/Social Isolation
- Emotional coping difficulties
- Child welfare services being involved in the home or removing them from their home
- Low communication skills
- Limited access to extracurricular activities
- Being withdrawn or difficult to engage
- Peer difficulties
- Being bullied or bullying others
- Lack of adult supports
- Violence (seen or heard) in the home, neighbourhood or school
- Low self-confidence
- Low self-compassion (hard on themselves)
- Questioning gender identity
- Questioning sexual identity
- Current or past eating disorder
- Self-mutilation (cutting, burning oneself)
- Trichotillomania (hair pulling)
- Emotional, physical or sexual abuse
- Suicide ideation/attempts
- Financial stress/abuse within family
- Vulnerable employment within family
- The death or terminal illness of someone close to them
- Arriving in Canada with refugee status
- Sibling with high needs
- Criminal/gang involvement
- Personal hygiene issues
- Chronic illness of family member
- Other mental health concerns
At school, the child is experiencing or has experienced:
Please check all risks/needs that apply to this child/youth. Please note that the following responses are voluntary and the information is used for statistical purposes only.
- Lack of class participation
- Disruptive behaviour in school
- Struggling academically
- Gives up easily/ low academic confidence
- Learning disabilities (suspected or confirmed)
- ADHD/ADD diagnosis (suspected or confirmed)
- Fetal Alcohol Spectrum Disorder (suspected or confirmed)
- Language barrier or ESL (English Second Language)
- Overachiever - high academic pressure
- Child attends learning program
- Difficulty interacting with adults
- Poor attendance
- Not engaged in school
A household member is experiencing or has experienced:
Please check all risks/needs that apply to this child/youth. Please note that the following responses are voluntary and the information is used for statistical purposes only.
- Substance use challenges
- Mental health illness
- Incarceration or involvement with police
Can you please share a few of your child's strengths?
Is there anything else we should know about your child that will help us serve them to the best of our ability?
Program Consent
Informed Program Consent - I hereby give permission to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION to make available their service to my child. It is my understanding that the intention of the Agency is to offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. In consideration for this service and other valuable consideration provided to my child by BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, 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 BIG SISTERS OF VICTORIA CAPITAL REGION, with the group facilitator so that my child’s needs may be best met. I understand that information about my child in the form of an attendance list may be shared, at the discretion of BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, for the purpose of grant reports and funding. I understand that this application is the property of BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. I also agree that my child will participate in the Pre- Match Training Program administered by BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY CHECKING "YES" TO THIS AGREEMENT, I ACKNOWLEDGE THAT: I am the parent/guardian of the child mentioned above, and I hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. 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.*
- Yes
Identity Check - I am aware that my child/youth will be asked to turn on their Zoom camera at the beginning of each session to confirm their identity to the B You Program Coordinator and B You Facilitators. This is one of the steps completed to help protect the participants of the group from unknown individuals joining the group. The child/youth is welcome to turn off their camera after the identity check/attendance is completed.*
- Yes
Photo Consent (Program Promotion/Awareness Raising) - Any photographs or video productions taken of children or youth by agency staff at recreational events or match outings, or otherwise authorized by the Executive Director or Board of Directors, may be used by the agency for the purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners for program promotion. My child’s FIRST name only, general personal circumstances, and general information about their match may be included.*
- Yes
- No
Online Program Consent - By checking 'Yes' below you are providing your consent for your child to engage in the B You Online Program, and have virtual contact through Zoom with up to twelve other program participants and 3 volunteer mentors for the duration of the program. The group will be monitored by Big Brothers Big Sisters Staff member at all times. You can find Zoom's privacy policy here: https://zoom.us/privacy*
- Yes
The person who filled out this form and gave consent for the child/youth to participate in B You is:
First Last
Signature:*
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Please email kait.burns@bigbrothersbigsisters.ca if you have any questions about this program or the application process.

Thank you!

B You Online Program

REGISTRATION AND INFORMED CONSENT

Fill out the form below to register for the Spring 2023 session of B You Online. Spring 2023 sessions will begin the first week of May.

B You Online Program Registration and Consent

ABOUT B You Online

Child/Youth Information

Family/Youth Background Information

Family Contact Information

Scheduling Information

About the Child/Youth

Program Consent

Please email kait.burns@bigbrothersbigsisters.ca if you have any questions about this program or the application process.