logo

Community-Based Youth Application and Parent Permission Form

Thank you for your interest in enrolling your child to be a Little Brother or Little Sister.

Please allow 5-7 days to receive follow-up contact from our Enrollment Specialist after submitting this application.

Call us at (406) 248-2229 with any questions.

Do you have legal custody of the child? required
Is there a person who shares legal custody of this child? required
If yes, are they aware and supportive of the child’s enrollment in the BBBS program?:

CHILD'S INFORMATION

The child's living situation? required
Is it okay to text parent?
Is it okay to text child?
Child's Race/Ethnicity (check all that apply):
May we contact you (the parent/guardian) at the work number listed above?
Please check the best number and time to contact you (the parent/guardian)? required

If we are unable to reach you, who is someone we could call who always knows how to reach you?

1. Does your child have siblings or relatives who are applying for the BBBS program at this time or who are currently in the program? required
2. Do you anticipate any significant life changes over the next year or have you had any in the past year, such as moving? required
3. Will your child be able to meet with their Big [once a week in the evenings or on the weekend for 1-2 hours] for the next year? required
4. Does your child have any physical or mental health conditions that might affect him or her participating in activities with a Big Brother/Big Sister? required
5. Does your child receive any of these services?
7. Is the parent/guardian receiving income assistance at this time? required
8. Is parent/guardian receiving assistance with housing (e.g. Section 8, residence in public-housing, etc.)? required
9. Is child eligible for free or reduced lunch? required
10. Household Annual Income: (total income of the adults the child lives with) required
11. Does your child have a parent/caregiver with current or past military experience? required
Branch:
Component:
Is the parent currently deployed?
Is the parent retired from the military?
Is the parent separated/discharged (other than retired)?
Does your child have a parent/caregiver that is considered fallen, wounded or disabled?
12. Does your child have a parent or parental figure (aunt, uncle, brother, etc.) who is incarcerated at this time? required
13. Has your child ever been arrested or involved in the juvenile justice system? required
Has your child ever been arrested or involved in the juvenile justice system? required
16. Where did you hear about Big Brothers Big Sisters? Please check all that apply and provide details below:

ADDITIONAL QUESTIONS:

By signing below, I give permission:

  1. For my child to participate in the Big Brothers Big Sisters Program;
  2. For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to transport my child to events and match activities;
  3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);
  4. To have my child participate in an in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests;
  5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
  6. For BBBS staff to provide contact information for me and my child to the volunteer.

I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I will be asked to provide additional information through an in-person interview. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information relevant to child-safety and well-being).

I certify that all of the information on this form is true and correct and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my qualification for the program.

I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me as his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable.

If my child is matched with a Big Brother or Big Sister I agree to support my child’s match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff as outlined in expectations (which includes communication at least once a month in the first year of the match), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff.

MODEL RELEASE FOR YOUTH UNDER 18 YEARS OLD

I hereby give Big Brothers Big Sisters, their assigns, licensees and legal representatives the irrevocable right to use my child’s name, picture, photograph, portrait, visual likeness, or voice in all forms and media in all manners, including photo, film, audio and video representations, as well as, BBBS of Yellowstone County Facebook page and monthly newsletter, for non-profit, public purposes, and I hereby waive any right to inspect or approve the finished product that may be created in connection therewith. I have read this release, and am fully familiar with its contents.

If you APPROVE, sign below:

I am the parent/legal guardian of the individual named above, I have read this release and approve of its terms.

Participant Release Form

Liability Release: I hereby release, indemnify and hold harmless Big Brothers Big Sisters of Yellowstone County from any and all liability in connection with injury (including any injury caused by negligence) in conjunction with participating in the Big Brothers Big Sisters program. I, likewise, hold harmless from liability any person transporting my child to or from any Big Brothers Big Sisters activity. I am also certain that my child is in good health and able to participate in the program activities. I certify that I am over 18 years of age and am competent to contract my name insofar as the above is concerned. I have read the foregoing release, authorization and agreement, before affixing my signature below and warrant that I fully understand the contents thereof.

POLICY ON CONFIDENTIALITY

I. Access to Confidential Records

In order for Big Brothers Big Sisters of Yellowstone County to provide responsible, professional service to clients, it is necessary for volunteers, clients and parents or guardians of clients to divulge extensive personal information about themselves and their families. The agency respects the confidentiality of client and volunteer records. Such personal information about clients and volunteers shall be shared only among the agency professional staff, with the exception of the specific situations described below.

Limits on Confidentiality

  1. Except as otherwise provided herein, confidential information concerning volunteers, clients and parents or guardians of clients may be released to or obtained from other organizations or persons only upon written consent to release/obtain such information by the affected volunteer, client or parent/guardian. Information will be shared in summary form. Duplicates of agency records will not be shared.
  2. Identifying information concerning volunteers and clients may be used in agency publications or promotional material upon consent, written or oral, by the volunteer or client.
  3. For purposes of program evaluation, audit or accreditation, and with the prior written approval of the Board of Directors, certain outside bodies, such as Big Brothers Big Sisters of America, may be granted access to client and volunteer records. These outside bodies shall follow this Agency policy on confidentiality. Outside bodies shall use such information only for the purpose(s) stated in the approval action of the Board of Directors.
  4. Client and volunteer information shall only be provided to law enforcement officials or the courts by the Executive Director pursuant to a valid subpoena.
  5. Montana law mandates the reporting of suspected child abuse by professional persons and officials listed in Section 41-3-201, MCA(1991). The agency’s professional staff shall report suspected child abuse to law enforcement authorities when the staff knows or has reasonable cause to suspect that a client is an abused or neglected child.

In addition, if the alleged offender is a Big Brother or Big Sister, the board president, legal counsel, BBBSA, and the agency’s insurance carrier will be notified. The match will be suspended immediately. 6. Should the agency professional staff receive information that a client or volunteer may be dangerous to self or others, the Executive Director may authorize any Agency worker to take steps necessary to protect threatened individuals, including but not limited to making a medical referral or a report to law enforcement authorities. Clients and volunteers shall consent to this provision. 7. The Board of Directors shall have access to volunteer or client records only upon authorization by motion of the Board. Such motion shall state who shall be authorized to review records, the specific purpose for such review and the period of time authorized for such review. Any member of the Board granted such authorization shall be bound by this policy on confidentiality. A violation of this policy shall constitute good cause for removal from the Board.

Nothing in this policy shall be interpreted as preventing the Executive Director from presenting a monthly program report to the Board of Directors. The program report may identify volunteers and children by name only throughout the match process from inquiry to closure. The Executive Director may summarize other information about the program not otherwise subject to the policy on confidentiality. 8. Volunteer and client information shall be provided to the agency’s legal counsel in the event of litigation or potential litigation involving the agency. Information provided to counsel shall be considered privileged pursuant to Section 26-1-803, MCA (1991). 9. At the time a child or volunteer is considered as a match candidate, information may be shared between the prospective match parties. However, the identity of the prospective match mate shall not be revealed until the parent and volunteer agrees to meet.

Each match party shall have the right to refuse the proposed match based on the anonymous information provided. The information to be shared may include:

  1. Volunteer: age, sex, race, religion, interests, hobbies, marriage and family status, sexual preference, living situation, reasons for applying to the program and a summary of why the individual was chosen for the particular match.
  2. Child: age, sex, race, religion, interests, hobbies, family situation, living situation, a summary of the client needs assessment and expectations for match participation.

Safekeeping of Confidential Records

All case files and case notes, both active and closed, shall be kept in locking file cabinets. No files may be removed from the premises without approval of the Executive Director. Closed files will be retained by the Agency for a minimum of seven (7) years, or until the child reaches the age of twenty one (21), whichever comes first, after which time basic demographic information will be saved, and the remained of the record may be destroyed.

Violations of Confidentiality

Violations of confidentiality by agency personnel may result in disciplinary actions, including warnings, suspensions, or termination. Violations of confidentiality by volunteers and parents will result in warnings and if necessary, match closure.

I understand the agency policy with respect to confidentiality of client and volunteer records.

I agree to program participation under the conditions it sets forth.

powered by Flow Forms