YOUTH APPLICATION

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BBBS of Southern Maine YOUTH APPLICATION & PARENT/GUARDIAN PERMISSION FORM

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Big Brothers Big Sisters Commitment + Communication Policy

Community-Based Program Requirements:

We ask for a 1-year commitment from the time your child/youth is matched.
Your child/youth and their Big will meet weekly or biweekly, depending on volunteer’s and family’s schedules.

Site-Based Program Requirements:

We ask for a 3-semester commitment from the time your child/youth is matched.
Your child/youth and their Big will meet weekly at school, in an after-school program or virtually.

Our standards require that each volunteer, child, and parent must complete regular, scheduled support contacts. For the first year of the match, contacts will follow a monthly cycle, moving to every three months after the one-year anniversary of the match. The contact may take place by phone, email, text or in person. The contact with your child may take place at school or by phone.

Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.

Hidden Fields

Youth Contact Owner ID

To look up the owner's email for notifications

Youth Contact Owner Email

For notifications

Youth Contact ID

Youth Enrollment ID

Additional Youth Found

YesNo

Who is completing this application?

Please explain:

Provider Contact Information

Name:

Email:

Phone Number:

Is the child/youth's parent/guardian aware you are completing this application?

YesNo

Is the child/youth aware you are applying for the program?

YesNo

If someone other than the child/youth's parent/guardian or custodial adult is completing this application, please be aware that signatures should only be completed by the legal parent/guardian. Parent/guardian involvement will also be required for the remaining steps of the enrollment process.

The PAF helps us gain valuable insight into the needs of the child and is used in two ways. First, we use your information in the acceptance process to ensure that this is an appropriate program for the child and their needs at this time. We are not a therapeutic or intervention model and we cannot be considered part of a clinical discharge plan or crisis plan. Second, we use the information you provide throughout the matching process to identify the best volunteer (Big) for the child, their needs, and their goals. Please provide as much information as you can about your client.

BBBSSM is committed to providing youth, 7-17 with strong and enduring, professionally supported relationships that can change their lives for the better, forever. We provide 1-to-1 mentors for children in Cumberland and York counties. Our focus is to help young people discover, ignite, and empower their potential.

Bigs must be at least 18 years old to apply to our program. They are thoroughly screened and vetted: we ask that they apply, provide three references, a comprehensive layered background check is completed, an interview is conducted and lastly, they are trained by our professional staff. However, they are not trained professionals; most do not have the skills or experiences to work with youth who require higher levels of support. Our services are not intended for youth who are in crisis or who are currently experiencing significant behavioral concerns.

We encourage you to ask questions if you are not sure if this program is the best fit for your client and thank you for your timely completion of this form.

1. Please briefly describe the child’s treatment, their strengths, any weaknesses, and need for your continued services.

Please provide a copy of the child’s most current treatment plan, if applicable. Please briefly describe the child’s treatment, their strengths, any weaknesses, and need for your continued services.

2. Please discuss the child’s ability to form and continue a one-to-one relationship with a non-professional volunteer mentor. Include any difficulties the volunteer is likely to experience with this child.

3. Please assess the child’s level of independence and their safety awareness in the community

4. What specific characteristics of a Big Brother/Big Sister would best benefit this child?

5. Additional Comments:

Youth Information

First Name

Last Name

Middle Name

Preferred Name/Nickname

Birthdate

Enter a date in the following format: mm/dd/yyyy

My child is under 13 years old

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?

Race/Ethnicity

American Indian or Alaska Native	Asian - Chinese
Asian - Filipino	Asian - Indian
Asian - Japanese	Asian - Korean
Asian - Other	Asian - Vietnamese
Black or African American	Hispanic - Cuban
Hispanic - Mexican,Mexican American, or Chicano	Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican	Middle Eastern or North African
Pacific Islander - Chamorro	Pacific Islander - Native Hawaiian
Pacific Islander - Other	Pacific Islander - Samoan
White or Caucasian	Other
Prefer not to say

Nationality/Country of Origin:

Hold CTRL+F to select multiple

Tribal & Regional Corporation Affiliations

School

Graduation Year

This is the year the youth will graduate.

School Account ID

Student ID Number

Youth's Email:

Youth's Phone

Is it okay to text child/youth?

Guardian Information

Guardian Contact ID

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Preferred Name/Nickname

Parent/Guardian Gender/Gender Identity

How do you identify?

Parent/Guardian Personal Pronouns

What pronouns do you use?

Mobile Phone

Is it okay to text you (Parent/Guardian)?

Home Phone

Work Phone

Work Phone Ext

Preferred Phone

Best Time to Call

Personal Email

Work Email

Alternate Email

Preferred Email

Contact Preference

Employer

Type NA if unemployed

May we contact you (Parent/Guardian) at the work number listed above?

Guardian's Relationship to Youth

Do you have legal custody of this youth?

YesNo

Is there a person who shares custody of this youth?

YesNo

Name

Phone

Are they aware and supportive of the youth's enrollment in the BBBS program?

YesNo

Family Information

Youth Living Situation

Living Situation Description

Languages Spoken in the Home:

English	Spanish
African Languages (Swahili, Bantu)	American Sign Language
Arabic	Asian: Other
Chinese	Creole
Dutch	Eastern European (Czech, Slovak)
French	German
Greek	Hebrew
Hmong	Indian (Hindi, Punjabi)
Italian	Japanese
Keres (West)	Korean
Nordic	Persian
Portuguese	Russian
Turkish	Lao

Primary language spoken by Parent/Guardian:

Primary language spoken by child/youth:

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing County

Please check here if your mailing address is different from your residential address:

Physical Address

Street Address

City

State

Zip Code

Emergency Contact

If we are unable to reach you, who should we contact in order to get ahold of you during an emergency?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship to Youth

Additional Questions

Agency Location ID

What is the primary reason for you wanting your child to have a Big?

Does your child have siblings or relatives who are applying for the BBBSSM program at this time or who are currently in the program?

YesNo

Other Siblings and Relatives in the Program

Please choose this child's relationship to the following people:

Name:	Relationship:
Application/Enrollment ID	Contact ID

Does your child know that you are applying for the program?

YesNo

Does your child want to participate?

YesNo

How did you hear about Big Brothers Big Sisters?

Referral Source ID

Do you anticipate any significant life changes over the next year, or have you had any in the past year? Examples of significant life changes include moving, job changes, or changes in family size or dynamics.

YesNo

Life Changes Description

Will your child be able to meet with their Big weekly or biweekly for the next year?

YesNo

Does the youth have any allergies?

YesNo

Allergies Description

Is the youth taking any medications?

YesNo

Medications Description

Does your child have any medical conditions that might affect them in participating in activities with a Big?

YesNo

Pertinent Medical History

How many adults and children currently reside in your household?

Does your child have a parent/guardian with current or past military experience?

Is the parent/guardian currently deployed?

YesNo

Does your child have a parent/guardian who is currently incarcerated?

YesNo

Has your child ever been arrested or involved in the juvenile justice system? Answering yes to this question will not affect your child's acceptance into Big Brothers Big Sister program

YesNo

What was their involvement?

Within the last year, has your child been in trouble at school?

Poor grades	Skipping school/classes
Behavior problems	Has been suspended
Has been expelled	Sent to an alternative school
None

Please describe:

Does your child receive any of these services?

Special education	Speech therapy
Tutoring	None

Please describe:

Is your child currently seeing a therapist/counselor or are they receiving any case management?

YesNo

Provider Assessment Release of Information

Counselor/Therapist/Case Manager Contact Information

First Name:

Last Name:

Provider Type:

Phone number:

Email:

Purpose of treatment:

Big Brothers Big Sisters of Southern Maine is a prevention program, where your child will be matched with a non-professional volunteer mentor, who will take them into the community. The safety of your child is our number one priority. If your child is receiving counseling, therapy, or case management we may need to contact the providers listed on this application to obtain a Provider Assessment Form and determine if our program is an appropriate fit. By signing below, you are authorizing Big Brothers Big Sisters of Southern Maine to speak with your child's providers regarding, but not limited to, the reason for services, their diagnosis, goals they are working on, and their level of safety awareness in the community. This release will remain in effect throughout the duration of your child's participation in our program and will expire upon closure.

By typing my name below, I, the parent/guardian, hereby authorize the release of confidential information pertaining to the child for which this application is being completed to Big Brothers Big Sisters of Southern Maine.

Name:

Date:

How would you describe the youth, in terms of participation in events, activities, or sports?

Which activities does the youth enjoy more?

What strengths does your child have that a Big might be able to help grow?

What are some of the needs your child has (examples could be emotional, social, behavioral, or academic) that a Big may be able to help them with?

Please provide their names and relationship to child/youth:

How would you describe the best mentor for your child?

We will make every effort to honor your preferences for your child's mentor. BBBS does not discriminate on the basis of race, ethnicity, gender, gender presentation, marital status, sexual orientation, or religion.

The following questions are asked for purposes of helping us apply for funding. We are a non-profit organization that raises every dollar needed to support youth in our community. The responses are entered into a database, then reported to funders anonymously.

Do you (parent/guardian) receive public income assistance at this time?

YesNo

Is your child eligible for free or reduced lunch?

YesNo

Annual Household Income (total income of the adults the child lives with): you are not required to answer this question.

Activity Interest Form

This form helps us get to know you better and provides us with valuable information we can use to make the best match for you. Please check the box next to each activity you like.

Playing Sports

BaseballBasketballBowlingCheerleadingField hockeyFootballGolfHockeyKickballLacrosseRollerbladingRoller-skatingSkateboardingSkiing downhillSkiing X-CountrySnowboardingSoccerSwimmingTrackTennisVolleyball

Games

Board GamesCardsCheckersChessFantasy leaguesImaginative playJigsaw puzzlesLegosPing pongPool/BilliardsVideo Games

Arts and Crafts

Bead workDancingDrawingKnitting/CrochetingModel buildingPaintingPhotographyPottery/ClayScrapbookingSewingSingingTheater/ActingWritingWoodworkingPlaying music

Reading

ComicsFictionMagazinesNewspapersNon-Fiction

Indoors

ComputersCookingGoing to the gymGymnasticsKarateListening to musicMoviesTV/VideoWatching sportsWeightliftingYoga

Outdoors

BeachBikingBoating/SailingBoogie boardingCanoeing/KayakingClimbingExploring/NatureFishingFrisbeeGardeningGeocachingGoing to the parkHikingHorseback ridingIce SkatingJoggingPicnicsSleddingSnowshoeingSurfingTaking a walk

Additional

Animal careAttending fairsAuto mechanicsCar racesGoing to the circusConcertsGo-CartsKite flyingMini golfMuseumsVolunteeringWindow shopping

Parent/Guardian Agreement

By checking the box below and providing my signature at the end of this form, I give permission:

For my child to participate in the Big Brothers Big Sisters Program;
For the volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to personally interact with and transport my child to events and match activities, if applicable and allowed by program type;
For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports);
To have my child participate in an intake interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout their time in the program containing questions about school, home life, the match, and personal interests to evaluate and improve program services;
To have my child talk with a Big Brothers Big Sisters staff person about personal safety;
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. I understand that incidents of child abuse or neglect, past or present, will 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, on behalf of myself and my child, completely release and forever discharge Big Brothers Big Sisters of Southern Maine and its employees, agents, members, volunteers and all other persons on its behalf, together with any successors in interest, heirs, attorneys, agents, representatives, and all persons acting by, through, under, or in concert with them from all known and unknown charges, complaints, claims, grievances, liabilities, obligations, promises, controversies, damages, actions, causes of action, suits, rights, demands, costs, losses, debts, penalties, fees, wages, attorneys’ fees and costs, and punitive damages of any kind or nature whatsoever, whether known or unknown, which I may have, or may have had, against Big Brothers Big Sisters of Southern Maine, arising from any participation 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 their guardian. I intend and understand that this release and discharge is to be interpreted and enforced so as to provide the broadest release and discharge possible as may be permitted by law. 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.

I accept the terms and conditions

Publicity and promotional materials for Big Brothers Big Sisters are conducted in a variety of forms. May we use your child's name, image, likeness, appearance, or basic biographical information in these materials?

Opt InOpt Out

Photo Consent and Release Form

,legal parent or guardian of

("Minor Child"), irrevocably consent:

For myself and Minor Child to any and all uses and displays of my or Minor Child’s name, image, likeness, appearance, basic biographical information, audio/video recordings, writings, artwork, and the like, in original form or in modified form, in whole or in part, in, on, or in connection with merchandise, advertising, publicity, marketing, fundraising, and the like, in printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America and Big Brothers Big Sisters of Southern Maine in their sole discretion, and by any of their affiliates, successors, partners, sponsors, donors, any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type, and any other authorized third parties, without further consent from me or Minor Child, without any royalty, payment, or other compensation to me or Minor Child, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use (the “Released Material”). In consideration of the mutual promises made herein, and for other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I hereby grant to BBBSA and its affiliates the right to use the Released Material as BBBSA and/or its affiliates may desire, in all media now existing or hereafter created and in all variations and forms including, but not limited to, internal or external publications or productions, informational or recruitment materials, marketing materials, fundraising materials, televised photography and/or recordings, advertisements, Public Service Announcements, and/or online and social media sites. The use of this information shall be at the sole discretion of BBBSA and/or its affiliates. I further grant to BBBSA and its affiliates the absolute right to use the Released Material in whole or in part, alone or in conjunction with any other image, name, writings or reproduction, in color or otherwise, for art, advertising, business, trade, or any other lawful purpose whatsoever, in perpetuity throughout the world. I understand and agree that all materials created by BBBSA and/or its affiliates that use the Released Materials are the property of and are owned by BBBSA, and that I cannot authorize their use by any other party. I further understand that BBBSA may authorize their use by a third party. I hereby irrevocably transfer and assign to BBBSA my entire right, title and interest, if any, in and to the Released Materials and all copyrights in the Released Materials arising in any jurisdiction throughout the world, including the right to register and sue to enforce such copyrights against infringers. I acknowledge and agree that I have no right to review or approve the Released Materials before they are used by BBBSA and/or its affiliates, and that BBBSA has no liability to me or Minor Child for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSA’s and/or its affiliates’ editing, alteration or use of the Released Materials. BBBSA has no obligation to use the Released Materials or to exercise any rights given by this Consent and Release Form. I hereby release BBBSA and its affiliates, employees, and agents, as well as any partner companies, from all claims, demands or liabilities and related financial costs that I or Minor Child may now or hereafter have arising in connection with BBBSA’s exercise of the rights hereby granted, and/or with the appearance or the Released Materials in any publication or production. These include, without limitation, claims for compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever.

I have read this Consent and Release Form completely. I fully understand what it means, and I agree to its terms. I have not been offered any additional consideration or enticement, nor have I been coerced to sign this document. I am voluntarily signing it for the purposes and considerations described.

YOUTH OUTCOMES AND CHILD OUTCOMES SURVEY PERMISSION

The Youth Outcomes Survey (YOS; 11 and older) and Child Outcome Survey (COS; 10 and younger) is intended to help Big Brothers Big Sisters evaluate our various mentor programs. The questions in this survey will ask your child about how things are for them at school and at home. It will only take about 10 minutes. Your child will be asked to take this survey prior to being matched, and again at the end of each year of their match or the end of each school year, for as long as they are matched in the program.

Parent/Guardian Consent

Child/Youth Assent:

Emergency Medical Information

Child's Name:

Date of Birth:

Parent/Guardian Name:

Parent/Guardian Email:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Name of Child's Doctor or Clinic:

Doctor/Clinic Phone:

Doctor or Clinic Address:

Health Insurance ID # (Blue Cross/Blue Shield/Mainecare, etc.):

By checking here, I consent to the performance of emergency medical care for my child as may be deemed necessary or advisable in the judgement of the physician, in the event I cannot be reached at the time of said emergency.

PHOTO CONSENT AND RELEASE FORM Parent/Guardian & Minor Child

I, the legal parent or guardian of "Minor Child" for whom this application is being completed, consent for myself and Minor Child to any and all uses and displays of my or Minor Child's name, image, likeness, appearance, basic biographical information (anonymously), audio/video recordings, writings, artwork, and the like, in original form or in modified form, in whole or in part, in, on, or in connection with merchandise, advertising, publicity, marketing, fundraising, and the like, in printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America and Big Brothers Big Sisters of Southern Maine in their sole discretion, and by any of their affiliates, successors, partners, sponsors, donors, any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type, and any other authorized third parties, without further consent from me or Minor Child, without any royalty, payment, or other compensation to me or Minor Child, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use (the "Released Material").

In consideration of the mutual promises made herein, and for other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I hereby grant to BBBSA and its affiliates the right to use the Released Material as BBBSA and/or its affiliates may desire, in all media now existing or hereafter created and in all variations and forms including, but not limited to, internal or external publications or productions, informational or recruitment materials, marketing materials, fundraising materials, televised photography and/or recording, advertisements, Public Service Announcements, and/or online and social media sites. The use of this information shall be at the sole discretion of BBBSA and/or its affiliates.

I further grant to BBBSA and its affiliates the absolute right to use the Released Materia in whole or in part, alone or in conjunction with any other image, name, writings or reproduction, in color or otherwise, for art, advertising, business, trade, or any other lawful purpose whatsoever, in perpetuity throughout the world.

I understand and agree that all materials created by BBBSA and/or its affiliates that use the Released Materials are the property of and are owned by BBBSA, and that I cannot authorize their use by any other party. I further understand that BBBSA may authorize their use by a third party. I hereby irrevocably transfer and assign to BBBSA my entire right, title and interest, if any, in and to the Released Materials and all copyrights in the Released Materials arising in any jurisdiction throughout the world, including the right to register and sue to enforce such copyrights against infringers.

I acknowledge and agree that I have no right to review or approve the Released Materials before they are used by BBBSA and/or its affiliates, and that BBBSA has no liability to me or Minor Child for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSA's and/or its affiliates' editing, alteration or use of the Released Materials. BBBSA has no obligation to use the Released Materials or to exercise any rights give by this Consent and Release Form.

I hereby release BBBSA and its affiliates, employees, and agents, as well as any partner companies, from all claims, demands or liabilities and related financial costs that I or Minor Child may now or hereafter have arising in connection with BBBSA's exercise of the rights hereby granted, and/or with the appearance or the Released Materials in any publication or production. These include, without limitation, claims for compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever.

I hereby authorize Big Brothers Big Sisters of Southern Maine to use photos and/or videos of my child in the following formats (please check all that apply): I recognize that I may revoke my permission at any time by submitting a written letter to Big Brothers Big Sisters of Southern Maine except to the extent that action has already been taken on the consent.

Big Brothers Big Sisters Website (www.somebigs.org)Print media (including our annual newsletter, monthly e-newsletter, brochures)Social media networks (Facebook, Instagram, Vimeo, Twitter)Please do not use any photos or videos of my child for any publicity purposes

I have read this Consent and Release Form completely. I fully understand its consent, and I agree to its terms. I have not been offered any additional consideration or enticement, nor have I been coerced to sign this document. I am voluntarily signing it for the purposes and considerations described.

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

Guidelines for Youth (LITTLES)

I will spend time with my Big weekly or bi-weekly for at least one year.
I will be dressed, ready, and on time for our scheduled outings.
I will not call/text/email my Big too often or at work unless it's OK, and I will call as soon as possible if plans have to be changed.
I will tell my Big when I like something and when I don't. I will also help to decide what we will do together.
I realize that my Big is my friend because they want to spend time with me. I know that other people are usually not included on our outings.
I understand that my Big is not required to spend money on me. My Big has offered me one of the biggest gifts possible-the gift of friendship.
I will be a friend to my Big, use good manners, and treat my Big with the same respect that I get from them.
I will share the responsibility of letting my parent/guardian know where we are going and when we will be home.
I will speak up when something is important to me and not expect my Big to guess what I'm thinking.
I know my parent/guardian has agreed to not limit my time with my Big as a punishment. I will not take advantage of this agreement by misbehaving on purpose.
I will not communicate with my Big through social networking sites such as (Facebook, Instagram, Twitter, Snapchat, TikTok) for the first year of my match. I will not post pictures of my Big on my profiles.
I will be in contact with my Program Manager every month, telling them what I like and what I don't like, so they can help if there are any problems. I will call them back when they have contacted me.

Guidelines for Parents/Guardians

I will give this special friendship time to grow and remember that this friendship is for the volunteer and my child and does not include others. I will be appreciative of the volunteer's time and efforts.
I will not ask more of the Big than they are already giving, their friendship to my child. For example, babysitting other children, running errands for my family, providing transportation for non-match activities, or fixing things around the house.
I will encourage my child to be considerate of the Big and their time by being dressed and ready on time for outings, and to be fed before outings unless previous arrangements have been made.
I will call the Big if plans need to be changed.
I will expect the Big and my child to be clear with me at all times as to with activity they will be doing, where and when they will do it, and what time they will return. I will be home when my child returns from an outing or let the Big know of an alternate plan.
I will never use the friendship or outings with the Big as a means of disciplining my child. If problems do arise concerning this, I will contact my Program Manager.
I will be in contact with my Program Manager every month to check-in about the match, express any concerns I may have, and notify the agency of any major changes in our household or family (change of phone number, moving, etc.)
I will be in contact with my Program Manager when they reach out to me for communication.

I have read the above youth safety guidelines and ground rules which define my responsibilities as the parent/guardian of a Little. I agree to abide by them as long as my youth is in the program and I understand that BBBSSM has the right to close my youth’s match at any time.

What is match support and why is it so important?

Big Brothers Big Sisters of Southern Maine takes great pride in creating and supporting long lasting and enduring matches. We ask that each of our matches commit to at least one year, starting the day you are matched. Most of our matches go well beyond that commitment. Our average match length is almost 3 years. Match support is what sets us apart and ensures that our matches are having fun and staying safe!

Match support is a regularly scheduled monthly check in where you discuss with your Program Manager how your match is going, and any needs/concerns you may have. Match support is also important in keeping you connected with our agency and upcoming opportunities. Match support is a non-negotiable requirement for Bigs, Littles and families when participating in our program. When the match reaches one year, the check-in schedule changes to quarterly. Of course, we are always here for support whenever you need. Quarterly check-ins are just as important as monthly check-ins, so it is vital that these are completed in a timely manner.

All parties must adhere to the match support schedule, if one part of the match does not respond to a request for check-in, the match will be at risk of closure. Parent/Guardian, Little and Big must all maintain the required schedule of communication and contact for the life of the match.

It is important that you understand that failure to comply with match support will put your match at risk of closure. Our Program team works with you to find a time that fits within your schedule. Please be mindful of scheduling with your Program Manager by responding in a timely fashion when they reach out to you.

Our policy on overdue match support states that failure to comply with required check-ins will be reason for immediate closure if the check-in reaches 30 days past due. We will send you a letter reminding you that match support is overdue and that we need to hear from you. Please be sure to get back to us within the timeframe the letter states. We are not able to re-open a match after closure for failure to comply.

Match support is a critical piece of our program in ensuring child safety. It offers the opportunity for the match to gain insight and knowledge on relationship building and for all of us to celebrate the success of the match. Relationships take time and need support to flourish and grow.

By checking this box, you are acknowledging the importance of match support and agree to comply with our required check in schedule.

Confidentiality Agreement

Please read this document in its entirety.

As a potential participant of Big Brothers Big Sisters of Southern Maine (BBBSSM or BBBS), I understand that I have access to confidential information about volunteers and/or clients and families. I fully understand and accept the responsibilities inherent in my role to maintain the complete confidentiality of all personal information, documents and parties who are engaged in this partnership (collectively, the "Confidential Information"), including myself, BBBSSM and all its affiliates and employees, public figures as well as all children and families that are served by this partnership. The obligation of confidentiality persists indefinitely and is not limited to the period of time beginning with my participation in BBBS and ending at the close of my participation.

In order for BBBSSM to provide responsible and professional services, it is necessary for volunteers, clients and parent/guardians of clients to disclose personal information. BBBSSM respects the confidentiality of client/volunteer information. Confidentiality applies to written records, electronic records, voice, verbal statements, pictures (motion or still) and the use of client/volunteer's name in agency publications. All records are considered property of the agency, not of agency staff, partner agencies, clients, parent/guardians or volunteers.

I further agree to the following terms:

In the event that an actual breach of confidentiality or a release of Confidential Information has occurred or if a situation which I reasonably believe may result in a breach of confidentiality comes to my attention, I agree to immediately notify the designated BBBSSM representative and/or any other appropriate BBBSSM staff member. I understand and agree that I am required to report such a breach or threatened breach of confidentiality regardless of whether the breach is caused by my own actions or by the actions of another person.

According to the confidentiality Policy, information from client/volunteer records may only be shared with individual/organizations as specified:

Identifying information regarding client/volunteer may be used in agency publications or promotional material only if the client/volunteer has given written permission.
Information shall be provided to law enforcement or courts only with a valid, enforceable subpoena.
Information shall be provided to BBBSSM legal counselor in the event of litigation or potential litigation involving the agency.
State law requires that suspected or disclosed child abuse, exploitation or neglect be reported to the Maine Department of Health and Human Services, Office of Child and Family Services.
Information regarding match relationship and match closure reasons shall be provided to other BBBS agencies and youth serving organizations if requested.
If agency staff receives information that indicates that a client/volunteer may be dangerous to themselves or to others, steps shall be taken to protect the appropriate party, including a report to the law enforcement authorities.
When a child/volunteer is considered for a match, information is shared between the prospective parties. The identity of the parties is not revealed until after the parties agree to the match. each party has the right to refuse proposed match based on the anonymous information provided. Information shared may include: age, sex, race, religion, education, interests, hobbies, marriage and family status, living situation, sexual orientation, reasons for applying to the program, expectations for the match, and all other information deemed relevant. The individuals to whom this information is provided agree not to share the information with any other person.
Certain outside bodies, including members of the Board of Directors, may have access to client volunteer records for the purpose of program evaluation, audit, accreditation, and/or for purposes of operating and making available approved software, on-line sites and login portals. All such authorized persons and representatives shall enter into a Confidentiality Agreement before receipt of any information from client/volunteer records.
Personally identifiable information of students which is obtained from education records provided by any school district or school will only be used or re-disclosed by BBBSSM or its authorized representatives in accordance with requirements of the Family Education Rights and Privacy Act (FERPA). Such information may not be re-disclosed to any third party (except back to the school district or school) without prior written consent of the school district or school, the parent or eligible student. Such information may not be used for any purpose other than the purpose stated in the agreement with the school district or school pursuant to which the information was obtained, and will only be disclosed to those authorized representatives of BBBSSM who have legitimate interest in the program pursuant to which the information is provided.

Other than the instances set forth above, information from client/volunteer records shall not be released unless accompanied by an authorized consent to release information form signed by the client/volunteer. If the client is under the age of 18, the consent to release information form must be signed by the student's parent or guardian.

By checking this box, I certify that I have read and understand the above confidentiality statement and release as provided by BBBS of Southern Maine.

Client Code of Conduct

Big Brothers Big Sisters of Southern Maine (BBBSSM) adopts this Code of Conduct to define acceptable standards of behavior for Parents/Guardians, Littles, and Bigs. This will guide the building of the relationship between Big/Little, Big/Parent/Guardian and Big/Little/Parent/Guardian/BBBBSSM. There will be no exceptions to the guidelines, they will be used in determining services and when necessary to end program involvement due to disruptive and/or unacceptable behavior. BBBSSM is committed and responsible for providing all participants with a rewarding and safe environment. Therefore, it is expected that all participants will:

1. Treat staff, families, volunteers and other participants with respect and honesty.

2. Refrain from discriminatory comments or actions and any other behavior that is derogatory to another person in our programs.

3. Inform staff of needs and changes in circumstances to receive relevant services.

4. Understand that BBBSSM works with multiple individuals with many levels of need, and staff may prioritize their time to deal with emergency or high need situations.

5. Maintain confidentiality of other clients, volunteers, and staff.

6. Client will understand that BBBSSM and its staff have limitations to the services they provide. When possible, we will share referral sources for other services.

7. Realize that access to services may have limits and eligibility does not automatically ensure services.

8. Deal with concerns and/or problems according to BBBSSM policies and procedures.

Refusal of Service:

Participants have a responsibility to be respectful and considerate of all participants and staff at BBBSSM. The decision to refuse, suspend or terminate services is made by the Program Director in consultation with the Executive Director. Wherever possible, when services are refused, BBBSSM staff will provide other community resources.

Reasons for refusal, suspension, or termination of services:

1. When the Executive Director, Program Director and program staff agree the client/participant has not followed the above code of conduct.

2. When a participant does not adhere to or follow the Program policies and procedures.

3. When a participant is/perceived to be threating, harmful, or inappropriate to fellow participants or staff.

4. When a participant behaves violently in any real or perceived manner.

5. When a participant is/perceived to be threatening or obscene in interactions with staff or other program participants.

By checking this box, I confirm that I have reviewed the above information and agree to adhere by the BBBSSM Client Code of Conduct for the duration of my involvement with the agency.

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Contact Information

YOUTH APPLICATION

BBBS of Southern Maine YOUTH APPLICATION & PARENT/GUARDIAN PERMISSION FORM

Additional Questions

Activity Interest Form

Parent/Guardian Agreement

Photo Consent and Release Form

YOUTH OUTCOMES AND CHILD OUTCOMES SURVEY PERMISSION

Emergency Medical Information

PHOTO CONSENT AND RELEASE FORM Parent/Guardian & Minor Child

Youth Safety Guidelines and Grounds Rules for Parents/Guardians

What is match support and why is it so important?

Confidentiality Agreement

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