Young Person Application 

Thank you, for your interest in programing provided by Boys & Girls Clubs Big Brothers Big Sisters of Edmonton and Area. 

On the following pages, we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information. Our agency will keep information provided confidential, based on our agency policy. 

Our agency works hard to create a safe, respectful, and inclusive environment for all who are involved with our programs. Sensitive information collected will only be used in a professional manner. Information we collect on gender identity, pronouns, preferred and legal names are used to find the right mentor for you and to create a safe space. If it is not safe for the agency to use the information provided, such as pronouns, please let us know how to best support you. 

Boys & Girls Clubs Big Brothers Big Sisters (BGCBigs) embodies the principles of diversity and welcomes participation regardless of race, religion, culture, gender, or sexual orientation. 
 

YOUR INVOLVEMENT:

Your signature at the end of this document acknowledges and agrees that:

  • You grant permission for your son/daughter to participate in the BGCBigs of Edmonton School Based Mentoring Program.  
  • This consent form is effective for the duration your child’s involvement of the BGCBigs School Based Mentoring program.
  • Your child will not have contact with his/her mentor outside of program hours.  If such contact is initiated, the match may be ended by the agency.  
  • You and your child will be asked to complete program surveys and evaluations as part of regular follow up and match monitoring of the program.
  • Your child’s teacher may be asked to also participate in the completion of surveys for evaluation information as requested by BGCBigs agency.
  • You understand that you have the right to examine your child’s file, and any child at 12 years of age has this same right.  Such an examination may be requested through the Principal of your child’s school or your program facilitator.
  • You agree to your child participating in a Pre-Match Program offered by the school and/or BGCBigs before your child is matched with a Mentor.  The Pre-match training program is designed to cover the following areas:

*Understanding of what mentoring is, boundaries and stages of the mentoring relationship, including endings; safe and healthy relationships

*Communication enhancement – including keep and speak secrets *role of your program facilitator.

  • You release BGCBigs of Edmonton & Area and your child’s school of all responsibilities and liabilities in connection to the services provided in good faith to your child.

If you encounter any issues with this form, please contact: Katrina Lee at katrina.lee@bgcbigs.ca or 780-822-2510

Boys & Girls Clubs Big Brothers Big Sisters of Edmonton and Area embodies the principles of diversity and welcomes the participation of all regardless of race, religion, culture, or sexual orientation. Our agency works to create a safe, respectful and inclusive environment for all who are involved with our programs.
 
 
 
 
 
 
 
 
Young Person's Information 
Program Description 

In School Mentoring: In person one on one, weekly mentoring during the school day for young people in grades 1 to 12.  Please note the program is for young people, who will be matched to an adult.


 
School Program Of Interest
 
 
Current School *
 
 
Grade
 
 
Teachers Name
 
 
 
Young Person's First Name*
 
 
Young Person's Last Name*
 
 
Young Person's Preferred Name (If different from first name)
 
 
Date of Birth (DD/MM/YYYY)*
 
 
Gender*
 
 
Specified Gender Identity If Not Listed
 
 
Pronouns *
 
 
Pronouns Specified If Not List
 
 
 
Young Persons Email
 
 
 
 
 
 
 
 
 
 
Address*
 
 
Apartment Number
 
 
City*
 
 
Province*
 
 
Postal Code*
 
 
 
 
 
 
 
 
 
 
 
Was the Young Person born in Canada?*
 
 
Cultural Identity*
 
 
Immigration Number/ Permanent Resident Card Number (if applicable)
 
 
Newcomer Status
 
 
Additional languages spoken
 
 
Preferred Language of Communication*
 
 
Will an interpreter be required for any meetings with young person or family?
 
Yes
No
 
If yes, please tell us what type of interpreter and what language
 
 
 
*If an interpreter is required, BGCBigs will provide one free of cost.  
 
 
 
 
Does the family currently have involvement with Children's Services?*
 
 
If yes, what type of involvement?
 
 
Social Worker name and contact information
 
 
 
 
 
 
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
Parent/Guardian Information

On the following pages we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information. Our agency will keep information provided confidential, based on our agency policy. 
  
Please provide information for the applicant (young person's) Primary Caregiver(s), Parent(s), or Leagal Guardian(s). We have provided space for 2 individuals, but only one primary caregiver is required. The primary caregiver will be the main contact person.  
 
Full name of Parent/Legal Guardian *
 
 
Does the Young Person live with this person?*
 
 
Relationship type*
 
 
Caregiver Specified Relationship Type if not previously listed
 
 
 
Custody of Young Person*
 
 
Who does the Young Person live with? *
 
 
 
Parent/Legal Guardian primary phone number*
 
 
Alternative phone number
 
 
Parent/Legal Guardian Email*
 
 
Best time of day to contact this person
 
 
 
 
 
 
 
Full name of other Parent/Guardian
 
 
Other Parent/Guardian relationship type
 
 
Does the Young Person live with this person
 
 
Other Parent/Guardian Address (If different from Primary Caregiver)
 
 
Other Parent/Guardian City
 
 
Other Parent/Guardian Province
 
 
Other Parent/Guardian postal code
 
 
Other Parent/Guardian primary phone number
 
 
Other Parent/Guardian alternative phone number
 
 
Other Parent/Guardian work or business phone number
 
 
 
 
 
 
Information provided will remain confidential. All programs are free and open to all young people, family income is not used to determine in program acceptance. If you would prefer not to disclose income on this application at this time you are able to do so.  
Income Source*
 
 
An estimate of your annual household income *
 
 
Number of people in household*
 
 
 
 
 
 
 
 
 
Siblings (Name, Age, Gender)
 
 
 
 
 
 
 
 
 
Emergency Contact Name*
 
 
Emergency Contact Relationship*
 
 
Emergency Contact Phone*
 
 
 
 
 
 
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
Program Information 

On the following pages we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information.Our agency will keep information provided confidential, based on our agency policy. 

  
Getting to Know Your Child
 

This information will help us begin to understand your child, which will help us find a good mentor.

 
Tell us about the young person's personality, strengths, and their interest/need for programming. there anything you would like us to be aware of that would assist us in finding the right mentor for your child? If yes, please describe: *
 
 
 
 
 
Please list any medical conditions or diagnosis of the young person*
 
 
Alberta Health Care Number*
 
 
 
 
 
 
 
Please list any allergies or dietary requirements (vegetarian, Halal, Celiac, does not eat pork, etc.)
 
 
   
 
 
Please list any interests your child has. Ex. Arts/Crafts, Cooking, Animals, Reading/Books, Board Games/Cards, Computers, Music, Sports, Building (Lego)*
 
 
 
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
Thank You for Completing the Application 

On the following pages we will be asking you to provide personal information for the applicant (young person) and their parent(s) or legal guardian(s). If you are referring a young person to one of our programs, we will also ask you for your basic contact information.Our agency will keep information provided confidential, based on our agency policy.  
 
Informed Consent
 
 
 
 
 

Media Consent
On occasion, your child’s photo may be taken in relation to their participation with BGCBigs programming.  These photos may be used in promotional materials and advertisement 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.  Do you consent to the photography and use of photos by BGCBigs?

 
Yes, I agree and consent for photographs and videos to be taken of my child
 
 
No, I do not consent for photographs and videos to be taken of my child
 
 
 
 
 
As the Parent/Legal Guardian, or the Referring Individual I authorize Boys and Girls Club Big Brothers Big Sisters of Edmonton and Area to use the information provided within their agency. I am consenting to receiving programs and services for my family, or contact to be made with this family.*
 
 
 
 
 
I agree that the information I have provided is true to the best of my knowledge. I acknowledge that some information will need to be shared with funding bodies as part of our agreement with municipal, provincial and federal funding sources.*
 
 
   
 
 
I consent that this document acts as my electronic signature and permission. *
 
 
 
 
 
Full name of Parent/Guardian completing form*
 
 
Email of Parent/Guardian completing form *
 
 
Name of Referring Individual (Complete if you are not a parent/caregiver referring a young person)
 
 
Name of Referring Organization/Agency (Complete if you are not a parent/caregiver referring a young person)
 
 
Email of Referring Individual (Complete if you are not a parent/caregiver referring a young person)
 
 
 
 
 
Please enter today's date (DD/MM/YYYY)*
 
 
 
Client