B You Summer Day Camp Registration B You Summer Day Camp 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 MindsB You Summer Day Camp is a FREE week-long, half-day program designed for gender-diverse and female-identifying youth between the ages of 10-14. Four groups in total will be run in the mornings and afternoons Monday through Friday during the weeks of July 10-14 and July 17-21. Groups will be approximately 12 mentees to three fully screened (Criminal Record Check included) and trained facilitators, assisted by BBBS Victoria staff. 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. While a draft calendar will be distributed outlining a rough agenda for each group, 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 InformationChild/Youth's Name* First Last Child/Youth's Birthdate* MM slash DD slash YYYY Child/Youth Gender* Child/Youth Ethnic IdentityThese responses are voluntary. Information provided will be used for statistical purposes only. English CanadianFrench CanadianFirst NationsMetisInuitMiddle EasternIndo ChinaSoutheast AsianEuropeanLatinxAfricanCentral or South AmericanOtherIf 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. If no known allergies, please write "N/A" or NKA. Child/Youth's Grade (as of September 2023)*We will try our best to match your child/youth with other participants in the same grade. 56789Child/Youth's School (as of September 2023)*Cedar Hill Middle SchoolGordon Head Middle SchoolShoreline Community Middle SchoolJohn Stubbs Memorial/ Ecole John Stubbs (K-9)Central Middle SchoolRockheights Middle SchoolSpencer Middle SchoolDunsmuir Middle SchoolRoyal Oak Middle SchoolQueneesh Elementary SchoolSavory Elementary SchoolVictoria West Elementary SchoolBayside Middle SchoolColquitz Middle SchoolGlanford Middle SchoolMonterey Middle SchoolArbutus Global Middle SchoolNorth Saanich Middle SchoolJourney Middle SchoolLansdowne Middle School/L'ecole LansdowneHomeschooledSouth Island Distance Education SchoolPender Island SchoolSaltspring Middle SchoolHigh SchoolOtherFamily/Youth Background InformationThis 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 SourceSelect 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 TypeSelect 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 InformationName of Primary Parent/Guardian* First Last Relation to Child/Youth*ParentLegal GuardianOtherPrimary Parent/Guardian Phone Number*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 Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Family Municipality/District Area*Based on CRD map.VictoriaEsquimaltColwoodLangfordHighlandsOak BaySaanichNorth SaanichCentral SaanichSookeSidneyView RoyalMetchosinOtherI am the parent/guardian of the child for whom I am making this application.* Yes No Emergency Contact #1 information here:*Emergency contact name, relationship to child. Emergency Contact #1 Phone Number*Required for emergency contact purposes. Emergency Contact #2 information here:*Emergency contact name, relationship to child. Emergency Contact #2 Phone Number*Required for emergency contact purposes. Camp InformationWhich group would you like your child to participate in?*B You Summer Day Camp is a week-long, half-day program running over July 10 - July 14 and July 17 - July 21. Please note that morning groups are reserved for youth ages 10-12 and afternoon groups are reserved for ages 12-13. We have a maximum of 12 participants per group, spots are available on a first-come-first-serve-basis. Please select which group(s) you are available for. Please note that once a group is full, a waitlist will form. July 10-14 from 9AM - 12PM (Ages 10-12) (WAITLIST) July 10-14 from 1PM - 4PM (Ages 13-14) (6 SPOTS REMAINING) July 17-21 from 9AM - 12PM (Ages 10-12) (WAITLIST) July 17-21 from 1PM - 4PM (Ages 13-14) (2 SPOTS REMAINING) Does your child have consent to walk or bus home alone?* Yes No My child will be picked up Approved Dropoff/Pickup Adult(s)*Please list the first and last names of adults who DO have permission to dropoff and pickup your child. Please let us know if there is anyone in particular who DOES NOT have permission to pick up your child. If your child is being picked up on the first day, please make sure the pickup person has photo ID so we are able to verify their identity (parents/guardians included). If your child has consent to walk or bus to/from the site, please enter "N/A." About the Child/YouthPlease 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 ConsentInformed 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 understand that this application is the property of BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. 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. Any program-related information shared with funders, including participant data and program feedback, is provided anonymously and all personal information that would identify you or your child is removed. I agree that personal information about my child may be shared, at the discretion of BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, with the group facilitators so that my child’s needs may be best met. I agree that my child will participate in the Pre-Match Training Program administered by BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. I agree that my child, under the supervision of the group facilitators, may leave the program site and walk to nearby greenspaces for outdoor activities, but will start and end each camp session at the fixed program site. 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 No The person who filled out this form and gave consent for the child/youth to participate in B You is: First Last
