School-Based Group Program 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

Scheduling Information

Has your child participated in a BBBS school-based program before?*

Yes

I'm not sure

If you answered "yes," please indicate the school-based program they participated in.

All Play

Go Girls

Game On

Unsure which program it was

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

Program Consent

If you have any questions or concerns about the consents below, please feel free to contact Miriah Gibson, Service Delivery Manager (miriah.gibson@bigbrothersbigsisters.ca) or 519.485.1801 ext. 227.

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

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

The person who filled out this form and gave consent for the child/youth to participate in a school-based group program is:*

First Last

Program Coordinators will confirm your identity through further communication.

Phone

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

School-Based Group Programming

Child/Youth Information

Family Contact Information

Scheduling Information

Program Consent