• PARENT/YOUTH APPLICATION

    PARENT/YOUTH APPLICATION

  • Parent's Relationship to Child:*

  • Parent's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is Parent Receiving Income Assistance?*
  • Youth's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Youth's Gender/Gender Identity*
  • Youth's Race/Ethnicity*

  • Free/Reduced Lunch*
  • Household Annual Income: (total income of the adults the child lives with)*
  • Special Education
  • 2. What is your living situation?*

  • 3. Does your child have any medical conditions that might impact him/her participating in activities with a Big Brother or Big Sister?
  • 4. Does you anticipate any significant life changes over the next year or had major changes in the past year?*

  • 5. Information regarding absent parent:

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Absent Parent's Gender/Gender Identity
  • How often does he/she see your child?

  • Is the absent parent in agreement with your request for a Big Brother/Sister for your child?
  • 6. We have a special program (Amachi Program) for children who have been impacted by parental incarceration. Would this program apply to your child?*
  • 7. Has your child had prior involvement with the Juvenile Justice System?*

  • By signing below, 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 Big Brothers Big Sisters of Flint and Genesee County 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 Flint and Genesee County, 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.

     

     

  • Date:*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Big Brothers Big Sisters of Flint & Genesee County 1176 Robert T. Longway Blvd. Flint, MI 48503 (810) 235-0617 Rev. 02/2020

  • COPPA PARENTAL CONSENT FORM

    Notice to Parents In compliance with the Children’s Online Privacy Protection Act (COPPA), parents (or legal guardians) of children under 13 years of age must consent to collections, uses and disclosures of the personal information of their children collected by Big Brothers Big Sisters of Flint and Genesee County on Big Brothers Big Sisters of Flint and Genesee County and NATIONAL websites, including Big Brothers Big Sisters of Flint and Genesee County website, bbbs.org, MatchConnect, bbbsa.force.com, forms.bbbs.org and formstack.io. Big Brothers Big Sisters of Flint and Genesee County’s COPPA statement is incorporated in the website Privacy Policy here: www.bbbsflint.org. Big Brothers Big Sisters of Flint and Genesee County may have collected your online contact information from your child, as well as the name of the child or the parent, in order to obtain your consent. Your permission is required for the collection, use, or disclosure of your child’s personal information. We will not grant your child access to any BBBS website account unless you provide us with permission. BBBS website accounts provide access to BBBS content, materials, and resources relating to BBBS programs and activities, including information pertaining to [MATCHES ETC.]

  • By signing and submitting this form to Big Brothers Big Sisters of Flint and Genesee County you certify that you consent to the collection, use and/or disclosure of your child’s personal information as described in Big Brothers Big Sisters of Flint and Genesee County’s privacy policy.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • You may revoke your consent at any time to refuse further collection and use of your child’s information. If you desire to revoke this consent, please write down your revocation of consent and scan and email the signed form to info@bbbsflint.org, or mail it to us at 1176 Robert T. Longway Blvd, Flint, MI  48503.

  • Are you a City of Flint Resident?*

  • Self-Certification of Income for City of Flint

    FY 2026 INCOME LIMITS DOCUMENTATION SYSTEM

  • HUD.gov  HUD User Home  Data Sets  Fair Market Rents  Section 8 Income Limits  MTSP Income Limits HUD LIHTC Database

     

     

    The Flint, MI MSA contains the following areas: Genesee County, MI;

    * The FY 2014 Consolidated Appropriations Act changed the definition of extremely low-income to be the greater of 30/50ths (60 percent) of the Section 8 very low-income limit or the poverty guideline as established by the Department of Health and Human Services (HHS), provided that this amount is not greater than the Section 8 50% very low-income limit. Consequently, the extremely low income limits may equal the very low (50%) income limits.

    Income Limit areas are based on FY 2026 Fair Market Rent (FMR) areas. For information on FMRs, please see our associated FY 2026 Fair Market Rent documentation system.

  • My total family size consists of* members, and total gross * income for all adult members $ *.

  • *         Gross annual income must include all sources of income (wages, child support, SSI, unemployment, pension, income from assets, etc., but does not include the income of live-in aids, per 24 CFR 5.403)

    I/We certify that the information given on household composition and income is accurate and complete to the best of my/our knowledge and belief.  I/We understand that false statements or information are punishable under federal law.  I/We also understand that false statements or information are grounds for termination of assistance.  I hereby certify that my household size and income are as stated above.  I consent to verification of this information by the service provider, the City of Flint, or other governmental officials as required.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Public Service Program Self-Certification of Income for City of Flint, Michigan CDBG Funded Activity

    Confidential Participant/Beneficiary HUD Demographic Information
  • Ethnicity (Choose One)*
  • Race*
  • Other Demographic Data (Select all that apply)*

  • *Gross annual income must include all sources of income (wages, child support, SSI, unemployment, pension, income from assets, etc.,but does not include the income of live-in aids, per 24 CFR 5.403) I/We certify that the information given on household composition and income is accurate and complete to the best of my/ourknowledge and belief. I/We understand that false statements or information are punishable under federal law. I/We also understandthat false statements or information are grounds for termination of assistance. I hereby certify that my household size and income areas stated above. I consent to verification of this information by the service provider, the City of Flint, or other governmental officials asrequired.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • PHOTO CONSENT AND RELEASE FORM

  • Media/Photo Release Form

    Authorization and Release 
    I hereby grant Big Brothers Big Sisters of Flint and Genesee County (BBBSFGC) and its affiliates, agents, employees, volunteers, and assigns the irrevocable right and permission to: 

    1. Photograph, videotape, or otherwise record me (or my child, if under 18), and;
    2. Use, reproduce, publish, and distribute those images, video, and/or audio recordings in whole or in part—without compensation—for any lawful purpose including, but not limited to: a) Print materials, b) Social media, c) Press releases, d) Website content, e) Event promotions Reports to donors and funders 
    3. I understand that these materials may be used in diverse settings within an unrestricted geographic area and may be edited or modified without further approval. 
      I understand that my (or my child’s) full name will not be used unless I give separate, written permission. 
    4. I release and discharge BBBSFGC from any claims or liability arising from the use of such materials. 
  • Permission for myself/my child to be photographed and/or recorded and for those materials to be used as describe above.*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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