PRISM Mentee Signup Form

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.