Game On Registration

Child/Youth Information

Youth Name*

First Last

Date of Birth*

Gender Identity/Expression*

Does your child/youth have any dietary restrictions or allergies?

Please list

Is there anything else we should know about your child that will help us serve them to the best of our ability? (diagnosis, behavioural concerns or medical conditions)

Child/Youth Current Grade*

We will try and match your child/youth with participants in the same grade.

Child/Youth's Current School*

If possible, we will try to match your child/youth with other participants who attend the same school.

Family Contact Information

Parent/Guardian Name*

First Last

Address

Street Address Address Line 2 City Province Postal Code

Phone

Email*

Enter Email Confirm Email

Zoom Account Email (Used for Online Program)*

This is the email that the child/youth will use to join the online program via Zoom. Security precautions taken.

Enter Email Confirm Email

Scheduling Information

Has your child participated in the Game On Program before?*

Yes
No
I'm not sure

Which days of the week is your child/youth available to participate in Game On?*

Please try to offer at least 2 different options for group days that could work for your child. Our Coordinator is working hard to group same-aged children/youth with each other and it's easier if we have more options to work with!

Select All
Monday Afternoons (4:15 - 5:45 PM)
Tuesday Afternoons (4:15 - 5:45 PM)
Wednesday Afternoons (4:15 - 5:45 PM)
Thursday Afternoons (4:15 - 5:45 PM)

Is there a friend your child/youth would like to be in the same group with

Please list the name of the friend below and we will do our best to match them in the same group. Please note that the other participant must also submit a registration form for the program

First Last

How would you like to receive your Game On Supply Kit?*

This program includes a free supply kit for yeach child/youth participating in the program. There are two options: Pick the kit up from one of our county offices at a designated date/time or you have the options to purchase your own program supplies using the list we will provide you. If these options don't work for you, please select "other" and the coordinator will be in touch with you to coordinate another plan.

Program Consent

If you have any questions or concerns about the consents below, please feel free to contact Kaitlyn Bruyns, Service Delivery Manager (kaitlyn.bruyns@bigborthersbigsisters.ca) or 519.537.6404 x226.

Informed Program Consent*

I hereby give permission to BIG BROTHERS BIG SISTERS OF OXFORD COUNTY 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 OXFORD COUNTY, 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 OXFORD COUNTY with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of BIG BROTHERS BIG SISTERS OF OXFORD COUNTY. I also agree that my child will participate in the Pre- Match Training Program administered by BIG BROTHERS BIG SISTERS OF OXFORD COUNTY. 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 OXFORD COUNTY 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

Identity Check*

I am aware that my child/youth will be asked to turn on their Zoom camera at the beginning of each session to confirm their identity to the Game On Program Coordinator and Game On Facilitators. This is one of the steps completed to help protect the participants of the group from unknown individuals joining the group. The child/youth is welcome to turn off their camera after the identity check/attendance is completed.

Yes

Photo Consent (Program Promotion/Awareness Campaigns)*

I hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters of Oxford County 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.

Yes
No

Online Program Consent*

By checking 'Yes' below you are providing your consent for your child to engage in the Online Game On Program, and have virtual contact through Zoom with up to twelve other program participants and 3 volunteer mentors for the duration of the program. The group will be monitored by Big Brothers Big Sisters Staff member at all times. You can find Zoom's privacy policy here: https://zoom.us/privacy I understand that: · as the parent/guardian, the group will adhere to the following rules which will be reinforced in the first few minutes of the meeting: o No sharing of personal contact information will be a highlighted rule o No screen sharing between participants o No private chats between participants · Any communication between your child/youth and other program participants that takes place outside of the Game On online platform and/or service-delivery dates cannot be monitored by the Mentoring Coordinator and should be approved and monitored at your discretion. I agree to: · provide continued supervision and support, checking in with my child following each group meeting and throughout the ten weeks, to determine how my child is responding to the program. - Ensure group privacy by not reading the chat room conversations. · contact BBBS immediately should any concerns arise related to my child’s participation in this program. · contact the Mentoring Coordinator if I or my child needs support to access and/or adjust to the online Game On program. · do my best to support my child’s participation in the weekly group meetings.

Yes

The person who filled out this form and gave consent for the child/youth to participate in Game On Online is:*

First Last

Program Coordinators will confirm your identity through further communication.

Comments

This field is for validation purposes and should be left unchanged.

Game On is now being offered online for male identifying young people between the age of 11 and 13!