YOUTH OBLIGATION RELEASE

YOUTH OBLIGATION RELEASE
Our program matches children between the ages of 7-17 years old; however, a child can be involved in the program until he/she turns 18 or graduates from high school. A letter will be sent to notify all children and adults who are not accepted into our program. It is the practice of Big Brothers Big Sisters of San Diego County NOT to inform the non-accepted party of the reasons for non acceptance. There is no guarantee that a match will be made. All children and volunteers who enter our program have the right to withdraw from the program at any time prior to matching.
Name of Youth*
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Confidential Information (This will not affect your application, but is used for statistical purposes only):
Family's Annual Income:*

Less than $10,000$10,000-14,999$15,000-19,999$20,000-24,999$25,000-29,999$30,000-34,999$35,000-39,999$40,000-44,999$45,000-49,999$50,000-59,999$60,000-74,999$75,000-99,999$100,000-124,999$125,000-149,999$150,000-199,999$200,000 or more
Does your child receive free or reduced school lunches?*

YesNo
Is either parent currently incarcerated?*

YesNo
If yes, does the child know?*

YesNo
CHILD MEDIA RELEASE
Print Parent/Guardian Name*
Print Child's Name*
I hereby give my permission for Big Brothers Big Sisters of San Diego County (BBBSSDC) to use pictures and information for promotion, marketing, and fundraising of the BBBSSDC program. I understand that no personal history information regarding or identifying me will be used by the agency indicated above without my permission. In giving this consent, I release BBBSSDC and anyone representing BBBSSDC from any obligation or liability otherwise owed to me in connection with any personal or ownership right I may have as a result of the sale, reproduction, or use of the above-referenced identifying information. This consent may be terminated at any time by me.
Yes, I provide consent to the above media release.No, I do not provide consent. My child’s image is NOT to be used in pictures or included in other information, marketing or fundraising for BBBS of SDC.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
POLICY STATEMENT
I have read and understand the Big Brothers Big Sisters of San Diego County policies. I agree to abide by the Big Brothers Big Sisters of San Diego County policies during my association with Big Brothers Big Sisters of San Diego County.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
CONFIDENTIALITY AGREEMENT
I have thoroughly reviewed the need for confidentiality and I understand and acknowledge the following:

1. All information that I may encounter about any child, child’s family, Big Brother/Big Sister, the Big Brother’s/Big Sister’s family or anything else of a confidential nature about any child or volunteer in any way connected with Big Brothers Big Sisters of San Diego County (BBBS of SDC) will be held confidential.

2. Any information that reveals or tends to reveal the identity of any person who is the subject of the record will be held confidential.

3. The identity of any person who contributes information to the subject record will be held confidential.

4. The results of any inquiry into school records or medical records of any description will be held confidential.

5. I will not discuss any confidential information pertaining to the child, child’s family, or the volunteer in the match that I am privileged to receive with any other person without the verbal or written permission of either the Program Director or CEO of BBBS of SDC.

6. I will only release prior approved information to the individuals for whom I have been given permission to release the information.

7. I agree to hold all related information confidential and, except as I may be legally required, will not disclose or release it to any individual or organization at any time.

8. BBBS of SDC agrees to hold all related information confidential and, except as the organization may be legally required, will not disclose or release it to any individual or organization at any time.

9. The information listed below is the exception in which it is relevant and necessary to disclose information to the other match party (parent/guardian or volunteer) in the prematch process prior to all parties accepting the match:

Information about the Little Brother/Little Sister to be shared with the Big Brother/Big Sister:

First name, age, general location of Little Brother’s/Little Sister’s home & travel time, grade in school , interests, personality, child/family situation and/or concerns which may affect the match, health and/or behavioral issues which may affect the match (Match Support Specialist will provide training/support to the Big Brother/Big Sister for these issues when applicable/available), religious preference, ethnicity, language(s) spoken, and firearms in the home.

Information about the Big Brother/Big Sister to be shared with the Parent/Guardian:

First name, age, general location of Big Brother/Big Sister’s home & and travel time, occupation, interests, motivation for volunteering, ethnicity, health conditions, including mental health, or relevant health history that may affect the match, sexual orientation, religious preference, marital status/living status, pets in the home, experience with children, language(s) spoken, and firearms in the home.

Information about the Big Brother/Big Sister to be shared with the Little Brother/Little Sister:

First name, interests, occupation, age, pets in the home, ethnicity, marital status/living situation, and religious preference.

I have read and agree to the above Confidentiality Statement.
Signature*

Clear
Date*

MonthDayYear
Date
Name Please Print*
Should be Empty:

YOUTH OBLIGATION RELEASE

CHILD MEDIA RELEASE

POLICY STATEMENT

CONFIDENTIALITY AGREEMENT