Boys Empowerment Participant Permission Form
 
 

Agency: Big Brothers Big Sisters of Toronto (BBBST) is a non-profit agency that focuses on providing Toronto’s children and youth with mentoring programs and opportunities. (https://toronto.bigbrothersbigsisters.ca)

Program: 8-15 selected participants (boys and those who identify) in (GRADE) will be matched with two adult (18+) volunteer mentors who are men, to engage in discussions and physical activities around topics such as conflict resolution, self-esteem, social media, being active and team work.  Activities include team-building games, sports and arts/crafts. All participants are provided with a snack during the program.

Outcomes: The goal of Boys Empowerment is to provide boys with information and support to make informed choices about active living, balanced eating, and to increase confidence and self-esteem.

Supervision: A school liaison (NAME OF LIAISON) will be on-site for the duration of the program. The program will be monitored via email, phone and in-person by the BBBST Program Specialist.

Where:  On school property at SCHOOL NAME

When:  Group is held on DAY starting START DATE at Lunch/Afterschool+ Time

Duration: 20-24 session program runs once a week on the specified program day mentioned above. Program does not run during holidays, school breaks, or PA days. The program will end on****. Please be advised that any school/program cancelations will result in an additional session past this date.

Guest Workshops: Boys Empowerment groups have the opportunity to host a number of educational and active workshops from outside guests. These vary per group and parents will be notified when guest speakers come into the group program during program time, onsite only.

Please read and sign the permission form and return to your child’s school. If you have any questions about the program, feel free to (contact Demari Grant, Boys’ Empowerment Specialist) at: Demari.Grant@bigbrothersbigsisters.ca or 416-925-8981 ex 4155.

PLEASE COMPLETE AND SUBMIT THIS COMPLETED PACKAGE ASAP AS SPOTS ARE FILLED ON A FIRST COME FIRST SERVED BASIS.

 
 
Application Details
 
A1. I am applying on behalf of my child to become a Mentee.*
 
 
A2. Application Received*
 
 
 
A3. Which Mentoring Program are you interested in for your child?
 
 
A4. Program Type
 
 
A5. How did you hear about us?*
 
 
 
 
Section 1: Child/Youth's Contact Information
 
S1.01. First Name*
 
 
S1.02. Last Name*
 
 
S1.03. Date of Birth*
 
 
S1.04. Age*
 
 
S1.05. Grade*
 
 
 
S1.06. Gender*
 
 
S1.07. Gender: Self-Identify
 
 
 
S1.08. Name of School*
 
 
S1.09. Street (and apartment # if applicable)*
 
 
S1.10. City*
 
 
S1.11. Province / Territory*
 
 
S1.12. Country *
 
 
S1.13. Postal Code*
 
 
S1.14. District Area*
 
 
MNC - North York, MNE - North Scarborough, MNW - Rexdale, MSC - Downtown, MSE - South Scarborough, MSW - Etobicoke
 
Check this map if you are unsure where you are in our District Areas: CLICK HERE for map  
  
 
S1.15. Is the Home Address Community Housing?*
 
Yes
No
 
S1.16. Is your child new to Canada?*
 
 
S1.17. If so, what is the youth's Newcomer Status?
 
 
S1.18. If so, when did they arrive in Canada?
 
 
S1.19. Does your child identify as a member of the BIPOC (Black, Indigenous, or a Person of Colour) community? *
 
 
 
S1.20. Child/Youth's Phone Number (if applicable)
 
 
S1.21. Child/Youth's Email (if applicable)
 
 
If the child/youth does not have their own mobile phone and/or email, please enter PARENT/GUARDIAN'S mobile phone and/or email.  
 
Section 2: Parent/Guardian Information
 
S2.01. Name of Parent/Caregiver*
 
 
S2.02. Relationship to Child*
 
 
S2.03. Primary Caregiver E-mail*
 
 
S2.04. Mobile Phone*
 
 
S2.05. Home Phone
 
 
 
Section 3: Emergency Contact Information
Emergency contact must be different from Parent/Guardian Information)  
 
S3.01. Emergency Contact Name*
 
 
S3.02. Emergency Contact Relationship*
 
 
S3.03. Emergency Contact Phone Number 1*
 
 
S3.04. Emergency Contact Phone Number 2
 
 
 
Section 4: Demographic Information
Please indicate if your child has been supported or affected by any of the following: 
 
N1. Support Worker
 
 
N2. Depression
 
 
N3. Anxiety
 
 
N4. Involved with Child Welfare (CAS)
 
 
N5. Language Support/Translator
 
 
N6. Behavioral Challenges
 
 
N7. Learning or Literacy Issues
 
 
N8. Chronic Physical Illness
 
 
S4.01. Chronic Physical Illness (If so, please specify):
 
 
S4.02. Does your child have allergies or dietary restrictions?
 
 
S4.03. Does your child have any medical needs or conditions? If yes, please explain:
 
 
 
*As a charity organization, we require the following information to apply for fundraising so we can continue supporting children across Toronto.* 
 
S4.04. Household Income*
 
 
S4.05. Income Source*
 
 
S4.06. # of Children in the Household*
 
 
S4.07. Custody (what best applied to the youth's family situation)*
 
 
 
Section 5: Program Pick-Up Information (Only required for elementary after school programs)
S5.01. Please select your child/youth's Pick-Up Information*
 
 
If your child will be picked up by another adult, other than the parent/guardian, please provide the pick-up authorization person's information below 
 
S5.02. Pick-up Authorization Person Name
 
 
S5.03. Phone Number
 
 
S5.04. Relationship to Child
 
 
 
 
 
Section 6: Informed Consent

I hereby give permission to Big Brothers Big Sisters of Toronto to make available their service to my child.  It is my understanding that the intention of the Agency is to offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program.

In consideration for this service and other valuable consideration provided to my child by Big Brothers Big Sisters of Toronto, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof.

I understand that the collection of personal information about me or my child will be held in strict confidence and is to be used solely for the purposes of administering the program.  I further agree that information about my child may be shared, at the discretion of Big Brothers Big Sisters of Toronto, with the group facilitator so that my child’s needs may be best met. 

I understand that this application is the property of Big Brothers Big Sisters of Toronto.  I also agree that my child will participate in the Pre-Match Training Program administered by Big Brothers Big Sisters of Toronto Staff.

I (Parent/Guardian) HAVE READ AND UNDERSTAND THIS AGREEMENT.

BY SIGNING THIS AGREEMENT, I (Parent/Guardian) ACKNOWLEDGE THAT:

 
IC. I, Parent/Guardian, of my child, hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by Big Brothers Big Sisters of Toronto. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child.*
 
 
IC. Parent/Caregiver's Name:*
 
 
IC. Child/Youth Full Name*
 
 
IC. Parent/Guardian E-Signature (type full name)*
 
 
IC. Today's Date*
 
 
 
 
Section 7: Media Consent
re: Child/Youth

Any photographs or video productions taken of children or youth by agency staff at recreational events or match outings, or otherwise authorized by the Executive Director or Board of Directors, may be used by the agency for purposes of promotional material 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.  
MC. Do you provide BBBST consent to use your picture and/or your child’s picture?*
 
 
MC. Parent/Guardian Full Name*
 
 
MC. Parent/Guardian E-Signature (type full name)*
 
 
MC. Child/Youth Full Name*
 
 
 
MC. Please check here if you do not want your picture or your child’s picture
 
 
MC. Today's Date*
 
 
Note: It is the parent/guardian's responsibility to notify the office if the status of this consent changes.  
 
Application Submission
 
Big Brothers Big Sisters agencies in Canada use a centralized online case file system. If your child has been involved in the past with another Big Brothers Big Sisters agency in Canada, the information you submit in this form will be transmitted and shared with both the agency you are applying to, along with the agency your child was previously involved with. If you do not want your child's information shared with the previous agency you had contact with, please contact enrolment.to@bigbrothersbigsisters.ca. 
 
 
A6. Date of Application*
 
 
 
 
 
Please check "I'm not a robot" before submitting.   
 
 
 
 
 
IMPORTANT NOTE: If you are not directed to a 'thank you for submission' page, there is missing information on the form. Please go back through the form an look for a note in red that says "This field is required. Please enter a value."