B You School-Based Registration

REGISTRATION AND INFORMED CONSENT

B You: Healthy Bodies, Healthy Minds 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: Healthy Bodies, Healthy Minds
B You: Healthy Bodies, Healthy Minds (formerly Go Girls) is a FREE 10-week program designed for gender-diverse and female-identifying and youth between the ages of 10-15. The groups meet weekly for approximately one hour and fifteen minutes during school hours on school property. Groups will be approximately 12 mentees to three fully screened (Criminal Record Check included) and trained facilitators. The objective of the program is to promote healthy living in youth through introducing a variety of sport and exercise methods, increasing knowledge of balanced nutrition, and encouraging self-compassion and social development. Each session is tailored to the needs and desires of participants in each group at the time of program delivery. Physical activities in B You include, but are not limited to, yoga, dance, walking, skipping, low-impact aerobics, and various games. These physical components are followed by a group discussion and a nutritional component in which participants learn about the importance of hydration while trying new foods that fuel their bodies. B You: Healthy Bodies, Healthy Minds aims to expand participant knowledge in active living, balanced eating, and self-compassion, while fostering strong mentoring relationships between participants and facilitators.
Child/Youth Information
Child/Youth's Name*
First Last
Child/Youth's Birthdate*
MM slash DD slash YYYY
Child/Youth Gender Identity*
Child/Youth Ethnic Identity
These responses are voluntary. Information provided will be used for statistical purposes only.
If you selected "Other" in the above question, please share here:
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*
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
Has your child participated in the B You (previously Go Girls) program before?*
- Yes
- No
- I'm not sure
Family Contact Information
Name of Primary Parent/Guardian*
First Last
Relation to Child/Youth*
Family Address
Street Address Address Line 2 City Province Postal Code
Family Municipality/District Area*
Based on CRD map.
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 student participating in B You if needed.
Enter Email Confirm Email
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 EAL (English as Additional 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 collect relevant personal information about my child from their school so that my child's needs may best be met. 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
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 (Keepsake Photos AND Media/Promotion)
- Yes (Keepsake Photos) but NO Media/Promotion
- No to both Keepsake Photos AND Media/Promotion
(AFTER SCHOOL GROUPS ONLY, all others select "N/A") Does your child have your permission to walk home by themselves?*
- Yes, my child will walk home.
- No, my child will be picked up by an approved adult.
- N/A
(AFTER SCHOOL GROUPS ONLY) If you said "no" to the above question, please list the approved adults that may pickup your child.
The person who filled out this form and gave consent for the child/youth to participate in B You is:
First Last
Name
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 registration process.

Thank you!

B You School-Based Registration

REGISTRATION AND INFORMED CONSENT

B You: Healthy Bodies, Healthy Minds Program Registration and Consent

About B You: Healthy Bodies, Healthy Minds

Child/Youth Information

Family/Youth Background Information

Family Contact Information

About the Child/Youth

Program Consent

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