B You School-Based Registration

REGISTRATION AND INFORMED CONSENT

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

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.

Name
This field is for validation purposes and should be left unchanged.
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 10-14. The groups meet weekly for approximately one hour and a half hours during school hours on school property. Groups will be approximately 12 mentees to three fully screened (Criminal Record Check included) and trained facilitators. PLEASE NOTE: Facilitators are volunteers, practicum students, or agency staff, and are NOT counsellors, social workers, or behavioural interventionists. The objective of the program is to promote healthy living in youth through introducing a variety of movement 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, playing at the park, 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. Social/emotional elements of B You are explored through varioue games, discussions, crafts, and worksheets. 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
Has your child participated in a BBBSV program before?*
- Yes
- No
- I'm not sure
Child/Youth's Name*
First Last
Child/Youth Preferred Name
Child's Pronouns
- She/Her
- They/Them
- She/They
Contact Information
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
Family Phone Number*
Family Address
Street Address Address Line 2 City Province Postal Code
Family Municipality/District Area*
Based on CRD map.
Name of Primary Parent/Guardian*
First Last
Relationship to the Child/Youth*
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.
Child/Youth Gender Identity*
Child/Youth's Birthdate*
MM slash DD slash YYYY
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
Did your child arrive in Canada with Refugee Status?
- Yes
- No
Family Income Level
- $0 - $30'000
- $30'001 - $50'000
- $50'001 - $75'000
- $75'001 and above
Family Income Source
Select all that apply.
- Employed FT
- Employed PT
- Student
- EI / Social Assistance
- Disability
- Other
Medical Information
Emergency Contact Name*
Emergency contact name, relationship to child, and phone number.
Emergency Contact Phone Number*
Required for emergency contact purposes.
Does the child/youth have any dietary restrictions or allergies?*
Please list below.
Does the young person have any specific medical conditions, mental or physical health concerns that the mentor or agency needs to know about? Do they have any allergies?*
If Yes, what are these conditions and how are they managed? Any medications? How do these conditions present in the young person’s daily life
School Information
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*
Are you willing to answer additional questions about your child/youth to help us understand and serve them better?*
Questions are voluntary and used for statistical purposes as well as to help us get to know your child better. Questions revolve around social emotional needs, school experiences, and home life.
- Yes
- No
About the Child/Youth
Please note the following responses are voluntary and the information is used for statistical purposes only.
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.
- Has Chronic Illness
- Identifies as 2SLGBTQIA+
- Peer Difficulties
- Mental Health Issues
- Generalized Anxiety
- Separation Anxiety
- Contact with Police
- Low Self-Esteem
- Difficulty Relating to Adults
- Difficulty Relating to Peers/Lack of Friends
- Challenges with Interpersonal Communication
- Emotional Coping Challenges
- Limited Access to Activities
- Socially Isolated
- Withdrawn
- Lack of Adult Supports
- Personal Hygiene Challenges
- History of Disordered Eating
- History of Abuse
- History of Self Harm
- Suicide Ideation/Attempts
- Criminal/Gang Involvement
- Substance Use Concerns
- Starting to Act Out
- Other
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.
- Bullying Other Kids
- Being Bullied
- Attention Difficulties
- Has Been Diagnosed with a Behaviour Concern
- ADHD/ADD (Suspected or Confirmed)
- On Behaviour Medication
- Fetal Alcohol Spectrum Disorder (suspected or confirmed)
- Difficulty with Authority
- Not Engaged in School
- Recent Suspension
- Poor Attendance
- Lack of Class Participation
- Struggling Academically
- Learning Disability/Difficulties
- Disruptive Behaviours
- Difficulty Staying Focused
- Lack of Motivation in School Environment
- Difficulty Interacting with the Adults in School
- English as Additional Language
- Child Attends an Individualized Leaning Program
- Other
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.
- Economic Adversity
- Caregiver is Unemployed
- Frequent Moves
- Unstable or Subsidized Housing
- Sibling(s) with High Needs
- Mental Health Issues in Family/Household
- Conflict/Violence in Family/Household
- Contact with Police in Family/Household
- Substance Abuse in Family/Household
- Hygiene Issues in Family/Household
- Illness in Family/Household
- Recent Death in Family/Household
- Child has a History of Loss/Bereavement
- Recent Immigration
- Living on Reserve
- History of Involvement with Child Welfare
- Parental Separation/Divorce
- Other
If you answered "other" to any of the questions above, please provide more details:
Child/Youth Strengths & Support Needs
Can you please share a few of your child's strengths?
Does your child require 1:1 support at school or in other group settings?*
- Yes
- No
- I would like to discuss in more detail via phone call
How does your child/youth deal with conflict or challenge?*
How do they react or respond when things don’t go their way
Are there times when, during moments of overwhelm or dysregulation, your child/youth has expressed themselves physically in ways that affected their safety or the safety of others?*
This may include bolting/fleeing, hitting/kicking, shutting down, etc.
- Yes
- No
- I would like to discuss in more detail via phone call
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
Signature*

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 UPDATED

About B You: Healthy Bodies, Healthy Minds

Child/Youth Information

Contact Information

Family/Youth Background Information

Medical Information

School Information

About the Child/Youth

Child/Youth Strengths & Support Needs

Program Consent

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