In-School Mentoring Parent/Guardian Forms - Big Brothers Big Sisters of Victoria Capital Region

In-School Mentoring Program

This form is to be completed by the parent/guardian of a child participating in the In-School Mentoring Program at one of our partner schools.

Child's Name:*

Parent/Guardian Name:*

First Last

Home Address:*

Street Address City Province Postal Code

Phone:*

Email:

More About the Child

Child's Gender:

Female
Male
Non-binary/Transgender/Gender diverse

Child's Date of Birth

Child Attends School in:*

Victoria or Saanich
Sooke or the West Shore
Salt Spring Island
Comox Valley
Brentwood Bay or the Peninsula

Child is enrolled at:*

Please provide the name of your child's school.

Why does your child want a mentor?

Is there anything you would like to be aware of that would assist us in finding the right mentor for your child?

Are there any classes you would rather your child not miss?

Are there any medical conditions, allergies or concerns we should know about?

What characteristics best describe your child?

Friendly
Outgoing
Shy
Withdrawn
Active
Helpful

What are your child's interests?

INFORMED CONSENT

This form must be signed by the child's parent or legal guardian.

Name of Child:

First Last

Informed Consent (School/Site Based 1:1 Program) - Parent*

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 18 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 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 and Area, with my child’s Mentor so that my child’s needs in a Mentoring relationship may be best met.

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 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 my name below, I am acknowledging that:*

I, the parent/guardian of the child named above, 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.

First Last

Signed on this date:*

Parent/Guardian Involvement

Although parents/guardians do not have to be involved in any particular way, the following options are available:

Yes, I’d like to be present when my child meets their mentor for the first time. This takes place during the school day
Yes, I’d like to receive a copy of the pre-match training materials prior to my child participating in the program
Yes, I’d like to receive updates about my child’s mentoring relationship
Yes, I’d like to be involved in some other way. I will contact Big Brothers Big Sisters at 250-475-1117 to learn more.

NEWSLETTERS AND UPDATES

You can opt out of receiving our newsletters and updates at any time. We will not sell or share your contact information with anyone

Yes, I’d like to receive the newsletter and agency updates from Big Brothers Big Sisters of Victoria and Area

Parent/Guardian Photo/Media Consent

From time to time, the following sorts of materials may be created in connection to school-based mentoring programs:

Name of Child:

First Last

1. Keepsake Items

I hereby give consent for photographs to be taken on school property or at agency-sponsored events for the purposes of keepsake items for my child and/or the mentor to have.

Keepsake items for match participants such as photos cards, scrapbooks, etc.)

2. Program Promotion / Awareness Raising

I hereby give consent for 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 name, personal circumstances, and general information about their match may be included.

Program information / promotional materials help us share information about our programs, including: Poster boards highlighting program activities for the school or agency to display; Stories or articles on programs or match experiences (for newsletter, website, etc.); and Brochures, slide shows, video shows, etc. (for general program promotion, recruiting new volunteers, providing funders and other parties more information about the work we do, etc.)

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

Do not use our pictures.

By entering my name below, I am acknowledging that:*

I, the parent/guardian of the child named above, completed this Parent/Guardian Photo/Media Consent form and I acknowledge that it is the parent/guardian’s responsibility to notify Big Brothers Big Sisters of Victoria if the status of this consent changes

First Last

Signed on this date:*