Informed Consent/Media Consent for In-School Mentoring Programs

Name of Child/Youth*

First Last

Informed Consent (Site Based - 1:1 Program)*

I hereby make formal application to BIG BROTHERS BIG SISTERS OF VICTORIA AND AREA to make available their service to my child. It is my understanding that the intention of the Agency is to match a responsible male/female adult, (minimum 19 years old, however, where appropriate supervision takes place, the volunteer may be younger), with my child for the purposes of shared activities, friendship and support. I understand that all efforts will be made to select a Mentor who is compatible with my child.

In consideration for this service and other valuable consideration provided to my child by BIG BROTHERS BIG SISTERS OF VICTORIA AND AREA, 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 consent to BIG BROTHERS BIG SISTERS OF VICTORIA AND AREA contacting any professionals involved with my family to obtain information for the purpose of assessing my application for a Mentor.

I further agree that all or part of the information herein may be shared, at the discretion of BIG BROTHERS BIG SISTERS OF VICTORIA AND AREA, with my child’s Mentor, and/or with the referring professionals, so that my child’s needs in a Mentoring relationship may be best met. 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 understand that I am under no obligation to accept a Mentor for my child, that the Agency is under no obligation to provide my child with a Mentor and that this application is the property of BIG BROTHERS BIG SISTERS OF VICTORIA AND AREA. I also agree that I and my child will participate in the Pre- Match Training Program administered by BIG BROTHERS BIG SISTERS OF VICTORIA AND AREA.

I have read and understand this agreement.

By entering your name below, you are acknowledging that:*

I am requesting service from Big Brothers Big Sisters for my child. I give the agency consent to assign a Mentor to my child. 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.

Parent/Guardian First Name Parent/Guardian Last Name

Parent Guardian Email*

Enter Email Confirm Email

Signed on this date:*

MEDIA CONSENT - Child/Youth

I hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters of Victoria and Area the use of any photographs, audio and/or video recordings of my child or youth as taken or produced by media personnel and/or National Office or Local Agency staff at recreational events or match outings, or otherwise authorized by the National President & CEO, local agency President/Executive Director/CEO or Board of Directors, and that this media may be used by Local Agency and/or by the National Office for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the local agency websites and social media). Photographs or video productions may also be shared with community and school partners for program promotion.
Please note that it is the parent/guardians responsibility to notify the office if the status of this consent changes.

I hereby give consent to the above agreement.

Please check here if you do NOT want your pictures or your child's picture used or if you have a safety concern:

Do not use our pictures.

Please note that it is the parent/guardians responsibility to notify the office if the status of this consent changes.

Parent/Guardian Name:

First Name Last Name

Signed on this date:*

Parent/Guardian Informed Consent/ Media Consent - (Site Based - 1:1 Program)