Child/Youth Annual Update Form for Community Mentor Program Child/Youth Annual Update Form for Community Mentoring in the Capital Regional District (Port Renfrew to Sidney) Section A: File UpdateTo be eligible for a mentor, your child must be aged between 7 and 16 years old and live in the Greater Victoria Area (from Port Renfrew to Sidney). Submitting this update form does not guarantee that a mentor can be found for your child.Child's Name:* First Last Parent/Guardian's Name:* First Last Relationship to Child: Does your child still want a mentor?* Yes No If your answer is no, please go to Section B at the end of this form and hit submitAddress for Child:The child/youth must in Greater Victoria (Port Renfrew to Sidney) to receive service from this Big Brothers Big Sisters agency. Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone:Email: Parent/Guardian Preferred Contact MethodWhat is the easiest way for us to reach you? Email Text Phone Call Parent/Guardian Preferred Contact TimeWhat is the best time to contact you? Morning Afternoon Evening Emergency Contact: Name First Last Emergency Contact: Relationship to Child Emergency Contact: Phone NumberEmergency Contact: Other Phone NumberName of Child's School: Name of Child's Teacher: Child's Grade:Kindergarten123456789101112Not in schoolNEWSLETTERS from Big Brothers Big Sisters of VictoriaStay informed of what's happening at BBBS! Fundraisers, Big/Little events, amazing opportunities and more! *Please note you can opt out at any time and we will not sell or share your contact information with anyone. Yes, I'd like to stay informed and receive the monthly newsletter from BBBS No, I do not want to stay informed. Activities List - Fun Things to Do TogetherIf your child's interests have changed since your initial application, please select the activities, events and/or places your child enjoys or would like to try with their mentor:Outdoor/sports activities: Outdoor Activities Air hockey/Foosball Archery Badminton Baseball Basketball Biking Billiards/Pool Boating (Canoe/Kayak) Bowling Camping Dancing Exercise/Fitness/Gym Fishing/Crabbing Football Frisbee Golf/mini-golf/driving range Go Karts Gymnastics Hiking/walking Hockey Kite Flying Lacrosse Ping Pong Rock Climbing Rugby Skate/Skim/Long boarding Skating Soccer Swimming Tennis Trampolines Watching sports Yoga Zip-lining Creative/playful activities: Indoor activities Animation/cartooning Arts & Crafts Baking or cooking Board or card games Building things (Lego) Card making Carpentry or woodwork Computers Creative writing Crochet/Knit/Sew Educational Activities E-sports Fashion & design Gardening Jewelry making Magic Making videos Mechanics Movies/TV Music Painting Photography Playing on the swings Poetry Pottery Puzzles Reading/Books Remote Control Vehicles Robotics Science Experiments Scrap-booking Self-Care / Spa Talking Video games Places and Events: Airplanes/Aviation Museum Animals - Bug Zoo or Petting Zoo Aquarium Art Galleries Astronomy/telescopes Beacon Hill Park Beach or tide pools Board Game Cafes Butchard Gardens Butterfly Gardens Cars and car shows Comedy or Improv shows CRD Nature Walks Cultural Activities Dance Performances Exploring downtown Festivals and local events Fisherman's Wharf Food tasting events Geo-caching or treasure hunts Inner Harbour Library Live Theatre Mineral World or Gem Shows Miniature World Movie Theatre Museums Opera Shopping Symphony The Breakwater Water parks matching considerationsIs it crucial that your child be matched with a mentor of the same gender?We do not match girls with male mentors as we always have a considerably higher number of boys on our wait-list. Yes No Is your child open to being matched with a female-identifying mentor to start? Yes No ABOUT YOUR CHILD'S EXPERIENCESYou do not have to complete this section if you are not comfortable sharing information about your child or family with us. However, we strive to match each child with the best available mentor and knowing more about your child’s experiences helps us determine who might be the best match for them. Child is experiencing/or has experienced:Please check all that apply. Social isolation at home, school or in the neighbourhood Parental separation or divorce MCFD or child welfare services being involved in the home A household member with a substance abuse problem A household member with a mental health illness A household member who has been incarcerated or involved with the police Being bullied or bullying others Violence (often seen or heard) at home, school or in the neighbourhood The death or terminal illness of someone close to them Arriving in Canada with refugee status or arriving in Canada within the last 5 years Financial stress in the household Insecure employment in the household Mental health illness Child is experiencing/or has experienced:Please check any/all that apply to this child. Peer difficulties Low self-esteem/confidence Difficulty relating to adults Difficulty relating to peers Low communication skills Emotional coping difficulties Limited access to activities Being withdrawn Lack of adult supports An eating disorder Emotional, physical or sexual abuse Self-harm Suicidal ideation/attempt Criminal/gang involvement Siblings with high needs Personal hygiene issues Living on reserve Chronic illness of a family member At school, child is experiencing/or has experienced:Please check any/all that apply to this child. Attention difficulties ADHD/ADD (suspected/confirmed) Taking behaviour medication Difficulty with authority Not engaged in school Poor attendance Lack of class participation Struggling academically Learning disabilities Disruptive behaviour in school Difficulties staying focused Lack of motivation Difficulty interacting with adults English as a second language Child attends learning program Is there anything preventing your child from fully participating in the program?Yes/No. If Yes, please explain. Have there been any changes in your child's life over the last year or since you originally applied for a mentor that we are not yet aware of (new medical diagnoses, additions/changes to the family, different custody/visitation arrangements, change in hobbies or interests, new schedule commitments)?Yes/No. If Yes, please explain. What would the ideal mentor for your child be like?Please explain. Confidentiality: Is there anything here that you DO NOT wish to have shared with the mentor?Please explain what you do not want to have shared. Section B: Submit FormName of Person who completed this form:* First Last Date form was completed: MM slash DD slash YYYY
