Little Brother/Little Sister Application Form

Little Brother/Little Sister Program Application & Parent Permission This form is to be filled out by the child’s parent or guardian. Please provide complete and accurate information.

Child’s Full Name Preferred name Date Child’s birth date Present age Child’s School Present grade Gender: Male Female Race/Ethnicity: Black White Hispanic Asian Other Program Preference: Site-Based (matches meet at school only) Community-Based

Parent/Guardian: Relationship to Child: Address City State Zip Home Phone Cell Phone E-mail Address Place of employment Work Phone Marital status Age Race Highest grade completed Preferred Language English Spanish Other

Other Parent/Guardian: Relationship to Child: Address City State Zip Home Phone Cell Phone E-mail Address Place of employment Work Phone Marital status Age Race Highest grade completed Emergency Contact (in addition to parent/guardian) Relationship to child Cell Phone Home Phone

Child’s Medical Conditions & Medicines: Allergies:

Living Situation ___ One Parent ___ Two Parent Number of people in household: _____

Does your family receive any of the following assistance programs? Check all that apply: ___Food Stamps ___TANF (cash assistance) ___Free/Reduced Lunch ___WIC ___Social Security ___Subsidized Housing/Section 8 ___Medicaid (adults) ___ Medicaid/FAMIS (children) ___Disability

Total current annual gross household income (before taxes) $______

PARENTAL CONSENT FOR PROGRAM PARTICIPATION I have read the parental consent for program participation information and agree to these terms. I give permission for my child to participate in the mentoring program of Big Brothers Big Sisters of Harrisonburg- Rockingham County.

I understand this information will be used with discretion and as an aid in determining the appropriateness of the program for my child, and whether other service referrals are indicated.

I understand there are no fees charged for this service, and that BBBSHR does not discriminate on the basis of to race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, veteran status, military obligations, and marital status in any of its activities or operations. ______Parent Initials PARENT/CHILD CONFIDENTIALITY POLICY I have read the Parent/Child Confidentiality Policy and agree to these terms. ______Parent Initials PARENTAL CONSENT TO PARTICIPATE IN RESEARCH I have read the Parental Consent to Participate in Research information and I understand what is being requested of my child as a participant in this study. I give my permission for my child to participate. I have been given satisfactory answers to my questions. I certify that I am at least 18 years of age. ______Parent Initials PARENTAL CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A CHILD FOR NON-PROFIT USE I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the child named above. I also grant Big Brothers Big Sisters the right to edit, use, and reuse said products for nonprofit purposes and program promotion including use in print, on the internet, and all other forms of media. I also hereby release Big Brothers Big Sisters of Harrisonburg-Rockingham County and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

I do not grant consent for my child to participate in media opportunities or publicity with Big Brothers Big Sisters.

PARENTAL CONSENT TO SHARE CONTACT INFORMATION

**_____ Please initial here if you are NOT willing to give consent for Big Brothers Big Sisters to share your contact information (including address and phone number) with a volunteer so they can maintain contact with your child during the summer months by mail or phone.

______Name of Parent/Guardian (Printed) Date

______Parent/Guardian Signature

Please read the following information and keep this page for future reference. You must designate your consent for each of the following on the Parental Consent Form to be returned with the Program Application.

PARENTAL CONSENT FOR PROGRAM PARTICIPATION

I give my permission:  For my child to participate in the Big Brothers Big Sisters mentoring program  For my child’s school to provide social, academic, medical, contact and other information about my child to Big Brothers Big Sisters (e.g. grades, attendance, IEP, disciplinary information, report cards, medical concerns, behavior reports, addresses, attendance records, phone numbers, etc).  For Big Brothers Big Sisters to receive and/or release pertinent information from social service agencies, mental health providers, and other related agencies concerning my child and family.  For my child to participate in all assessment and evaluation services and for my child to complete a questionnaire containing questions about school, home life, and personal interests.  For the information provided by myself, my child, the child’s family and other agencies to be shared with discretion to a potential volunteer for my child  For myself and my child to participate in all assessment and evaluation services and I consent to my child completing a questionnaire containing questions about school, home life, and personal interests.  For myself and my child to talk with a Big Brothers Big Sisters staff person on regular basis to help ensure safety and a quality match.  For the information provided by myself, my child, the child’s family, and other agencies to be shared with discretion to a potential volunteer for my child. I understand that any potential volunteer is asked to hold this information in confidence.  For Big Brothers Big Sisters staff members and other agents acting under permission of the agency to transport my child.

PARENT/CHILD CONFIDENTIALITY POLICY

Big Brothers Big Sisters of Harrisonburg and Rockingham County respects the confidentiality of child, parent, and family records and, with the exceptions listed below, shares information only among the agency professional staff. All records are considered the property of the agency and not the agency workers. Records are not available for review by the parents or mentors.

 Child and family records may be disclosed for purposes of program evaluation, audit, or accreditation, as well as to certain outside bodies such as Big Brothers Big Sisters of America.  Members of the Board of Directors or evaluators appointed by the Board have access to files upon authorization of the Board of Directors.  The Executive Director may allow the release of information to third parties who provide services for Big Brothers Big Sisters of Harrisonburg-Rockingham County regular business operations.  Information may be disclosed as may be required by law, such as disclosures to law enforcement or for judicial or administrative law proceedings.  Information may be provided to an agency’s legal counsel in the event of litigation, potential litigation involving the agency, or other legal matters.  State law mandates that suspected child abuse be reported to the Department of Social Services.  If an agency worker receives information indicating that a child may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities.  At the time a child is considered as a match candidate, information is shared between prospective match parties. Information about the child may include such items as age, sex, race, religion, interests, hobbies, family situation, etc.  In all other situations, information will be released to other individuals or non-BBBS organizations only with the parent/guardian’s written consent

PARENTAL CONSENT TO PARTICIPATE IN RESEARCH

Consent for My Child to Participate in Research: Big Brothers Big Sisters of Harrisonburg Rockingham County (BBBSHR) is currently participating in a research study conducted by researchers from James Madison University. The purpose of this study is to look at the impact of training and support for mentors on the quality of mentor-mentee relationships and on mentee outcomes.

Risks and Benefits: Researchers do not perceive more than minimal risks from your child’s involvement in this study. All potential risks are non-physical: risks involved in this type of study include increased assessment time. Benefits from participation in this research include possible direct educational and relational benefits and indirect emotional benefits. You and your child may have the opportunity to offer valuable feedback on the quality of your BBBSHR experience. This feedback could lead to increased knowledge about the BBBSHR program and improvements in the program. There are additional incentives available to your child in the form of raffled prizes at the end of the research study for completing assessments (these prizes will not exceed $50 in value).

Confidentiality: The results of this research will be presented at conferences and in academic journals. The results of this project will be coded in such a way that your child’s identity will not be attached to the final form of this study. The researcher retains the right to use and publish non-identifiable data. While individual responses are confidential, aggregate data will be presented representing averages or generalizations about the responses as a whole. All data will be stored in a secure location accessible only to the research team and BBBSHR staff. Upon completion of the study, all information that connects individual respondents with their answers will be destroyed.

Participation & Withdrawal: Your child’s participation is entirely voluntary. You are free to choose not to participate. Should you choose to participate, you can withdraw at any time without consequences of any kind. You and your child will be able to maintain your relationship and standing in the BBBSHR program.

Questions: If you have questions about the study, would like to receive the final aggregate results of this study, or have questions about your rights as a research subject, please contact:

Questions about the Study Questions about Your Rights as a Subject Dr. Amanda Teye Dr. David Cockley Department of Political Science Chair, Institutional Review Board James Madison University James Madison University (540) 568-5308 (540) 568-2834 [email protected] [email protected]

PARENTAL CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A CHILD FOR NON-PROFIT USE

Explanation to Parents: As a donor and volunteer supported, nonprofit organization, Big Brothers Big Sisters often seeks opportunities to share our stories with our community. We utilize several channels of media including newspaper, radio, video, social media, our agency website, and print publications such as brochures and flyers. Please complete the parental consent form to indicate your preferences regarding your child’s participation in media opportunities when involved in a Big Brothers Big Sisters activity. It will remain on file with Big Brothers Big Sisters. You may update your preferences at any time by contacting your Match Support Specialist.

Please designate your consent for program and research participation, media preferences, and acknowledgement of the confidentiality policy on the Parental Consent Form to be returned with the Program Application.