Virtual Mentee Application

Child's Information

Child's Legal Name(Required)

First

Last

Preferred Name

Date of Birth(Required)

Gender(Required)

Child's Pronouns(Required)

Child's School(Required)

Child's Grade

Caregiver Information

Caregiver's Legal Name(Required)

First

Last

Phone(Required)

Email(Required)

Informed Consent

I hereby make formal application to Big Brothers Big Sisters of Waterloo Region (BBBSWR) to make available their service to my child. It is my understanding that the intention of the Agency is to match a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), with my child for the purposes of shared activities, friendship and support. I understand that all efforts will be made to select a Mentor who is compatible with my child.

In consideration for this service and other valuable consideration provided to my child by BBBSWR, 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 BBBSWR, with my child’s Mentor so that my child’s needs in a Mentoring relationship may be best met.

I understand that I am under no obligation to accept a Mentor for my child, that the Agency is under no obligation to provide my child with a Mentor and that this application is the property of BBBSWR. I also agree that my child will participate in the Pre- Match Training Program administered by BBBSWR.

I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT

I hereby request Big Brothers Big Sisters service for my child. I give the agency my consent to assign a Mentor to my child. 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.

Caregiver Name(Required)

First

Last

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Virtual Tutoring Application Package

Child's Information

Caregiver Information

Getting to know your child

Choosing A Mentor

Your Involvement

Informed Consent