Young Person Club 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. 

The Agency provides a variety of program opportunities and supports. Community Clubs are safe and fun places for kids to go after school and during the summer. They provide kids with opportunities to connect with positive role models and peers, enjoy a healthy meal or snack, and explore our core program areas: arts and culture, physical activity, health and nutrition, academic support, personal growth, empowerment, life skills, and leadership. For your child/youth to participate in any of the programming at Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area (BGCBigs). Once the form is completed and you have signed the form, your child will be able to participate in our programming.  Please speak to the Club staff for more information about all age programs. 


If you encounter any issues with this form, please contact: Rachel Leaf at rachel.leaf@bgcbigs.ca or 780-490-6843.


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 

Club Programs: Registered after school group programing for young people ages 6 to 18

 
Club Program of Interest
 
 
 
Please select your preferred Club location*
 
 
 
 
 
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
 
 
 
Walk Home Permission*
 
 
If NO, please indicate who is authorized to pick them up or walk them home.
 
 
 
 
 
 
 
 
 
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.  
 
School that the young person will attend during the 2024/2025 school year*
 
 
Grade young person will be in during the 2024/2025 school year*
 
 
 
 
 
 
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, and their need for services*
 
 
 
 
 
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.)
 
 
   
 
 
 
Click "Next" to continue your application. At any time you can click "Previous" to review or edit previous pages. 
 
 
CONSENT FOR PROVISION OF SERVICE:
 
Informed Consent Section 1
 
 
 
Informed Consent Section 2
 
 
 
Informed Consent Section 3
 
 
 
Informed Consent Section 4
 
 
 
Informed Consent Section 5
 
 
 
 
 
Informed Consent Section 6
 
 
 
 
 
Informed Consent Section 7
 
 
 
 
 
Informed Consent Section 8
 
 
 
 
 
Informed Consent Section 9
 
 
 
 
 
Full Name of child*
 
 
 
Informed Consent Response *
 
Yes, I agree to the above
 
 
 
 
Media Consent
 
 
 
Media Consent Response *
 
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
 
 
Confidentiality Agreement
 
 
 
Confidentiality Agreement Response*
 
Yes, I agree to the above
 
 
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