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

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

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
To look up the owner's email for notifications
For notifications
Youth Information
Enter a date in the following format: mm/dd/yyyy

Hold CTRL+F to select multiple

This is the year the youth will graduate.
Guardian Information
Type NA if unemployed
Family Information

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

Additional Questions




Other Siblings and Relatives in the Program
Please choose this child's relationship to the following people:




















Provider Assessment Release of Information
Counselor/Therapist/Case Manager Contact Information
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.





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. 




Activity Interest Form

This form helps us to know you better and provides us with valuable information we can use to make the best match for you. Please place a check mark after each activity you like.

Parent/Guardian Agreement

By checking the box below and providing my signature at the end of this form, 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 personally interact with and transport my child to events and match activities, if applicable and allowed by program type;
  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 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;
  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. 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 [Agency Name] 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 [Agency Name], 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.

Photo Consent and Release Form

I,
,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. 

 

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. 

Emergency Medical Information

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.



Youth Safety Guidelines and Grounds Rules for Parents/Guardians

Guidelines for Youth (LITTLES)

  1. I will spend time with my Big weekly or bi-weekly for at least one year.
  2. I will be dressed, ready, and on time for our scheduled outings.
  3. I will call my Big since Bigs like to get phone calls, too. I will not call 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.
  4. 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.
  5. I realize that my Big is my friend because they want to spend time with me. I know that other people are not usually included on our outings.
  6. I understand that my Big is not required to spend money on me. My Big offered me one of the biggest gifts possible-the gift of friendship.
  7. I will be a friend to my Big, use good manners, and treat my Big with the same respect I get from them.
  8. I will share the responsibility of letting my parent/guardian know where we are going and when we will be home.
  9. I will speak up when something is important to me and not expect my Big to guess what I'm thinking.
  10. 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.
  11. I will not communicate with my Big through social networking sites such as Facebook, Instagram or Twitter, for the first year of my match. I will not post pictures of my Big on my profiles.
  12. 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
  1. 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.
  2. 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.
  3. I will encourage my child to be considerate of the Big and their by being dressed and ready on time for outings, and to be fed before outings unless previous arrangements have been made.
  4. I will call the Big if plans need to be changed.
  5. I will expect the Big and my child to be clear with me at all times as to what 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 alternative plan.
  6. 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.
  7. 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.).
  8. I will be in contact with my Program Manager when they reach out to me for communication.
Guidelines for BBBS Program Manager
  1. I will have regular contact (phone/email) with the child/youth, the volunteer, and the parent/guardian to discuss how the match is going and address any concerns.
  2. I will respect the time, energy, and care that all parties are giving to make this friendship possible.
  3. I will encourage the child/youth, volunteer, and parent/guardian to be honest with each other in sharing both positive and negative feelings.
  4. As with any friendship, I know that there will be good and difficult times. I will support the match during all its ups and downs.
  5. If problems cannot be resolved or if any party involved is no longer able or willing to fulfill their commitment, I will close the match. The agency will always do what is in the best interest of the child/youth.
Guidelines for Volunteers (BIGS)
  1. I will meet with my Little weekly or bi-weekly for at least one year. I am always responsible for calling the parent/guardian to set up outings. I will not stop my regular contacts with my Little without explaining the circumstances to all parties. 
  2. I will be on time and will call my Little and the parent/guardian if plans need to be changed. 
  3. I will not make promises which I cannot keep.
  4. I will not break any law while with my Little.
  5. I will not use my cell phone while operating my motor vehicle with my Little in the car. Maine State Law prohibits use of handheld devices while driving. BBBSSM prohibits any use of a cell phone while driving with your Little in the vehicle.
  6. I will immediately report any child abuse or neglect to the BBBSSM staff. In the event that the BBBSSM office is closed and I believe my Little is in immediate danger, I will call the local police.
  7. I will support my Little's relationship with their family and make no attempt to impose my values on them.
  8. I understand that I will learn personal information about my Little and their family, which I will keep confidential.
  9. I will be in contact with my Program Manager once a month to check-in about my match. I will respond to any communication that I receive from BBBSSM staff.
  10. I will not engage in any type of drug or alcohol use prior to or during a match outing. I will not smoke cigarettes or use other tobacco products while with my Little.
  11. I understand that no overnight visits will be permitted within the first year of the match. After the first year, I will obtain permission from my Program Manager BEFORE an overnight occurs.
  12. I understand that I will not visit my home with my Little for the first 3 months of our match. After 3 months, I will discuss home visits with all parties and receive approval from my Program Manager. 
  13. I understand that match outings should generally be kept to a one-to-one basis but may occasionally include friends or family members of either myself or my Little.
  14. I will maintain open communication at all times and never ask my Little to keep a secret. 
  15. I will respect the personal space of my Little and avoid inappropriate physical contact (e.g. backrubs, sitting in laps, tickling, wresting, etc.).
  16. I will never be physical with my Little or use verbal or emotional means of discipline.
  17. I will never display or discuss any materials of a sexual nature with my Little.
  18. I will provide separate areas for my Little to change clothes, bathe, and/or sleep when these actions take place during a match outing.
  19. I will not communicate with my Little or their family members through social networking sites (such as Facebook, Instagram, Twitter) for the first year of my match. I will not post pictures of my Little on my profiles.

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:
  1. 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:
  1. Identifying information regarding client/volunteer may be used in agency publications or promotional material only if the client/volunteer has given written permission.
  2. Information shall be provided to law enforcement or courts only with a valid, enforceable subpoena. 
  3. Information shall be provided to BBBSSM legal counselor in the event of litigation or potential litigation involving the agency.
  4. 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. 
  5. Information regarding match relationship and match closure reasons shall be provided to other BBBS agencies and youth serving organizations if requested.
  6. 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.
  7. 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.
  8. 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.
  9. 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.


See the big difference our mentors make in real time.