Arts and Crafts Application (May-June 2024)

Play On – Parent Permission

Arts and Crafts at Big Brothers Big Sisters

***THIS ROUND OF THE PROGRAM IS CURRENTLY FULL***

Wednesdays 2:30ish – 4:45pm, May 8th – June 12th, 2024)

Play On is an exciting all-inclusive mentoring program being offered through Big Brothers Big Sisters of Central Vancouver Island (BBBSCVI). The goal of Play On is to provide children/youth with information and support to make informed choices about active living, balanced eating, and feeling good about themselves!

A group of 4-5 participants will be paired with 1 mentor that has been screened by BBBS of Canada National Standards. The program will run for 6 weeks on Thursdays from 2:30ish to 4:45pm at Big Brothers Big Sisters, 2030 Northfield Road. Each session will include 1 hour doing arts and crafts, a snack, and interactive games.

Your child has the option to withdraw from the program at any time.

As part of the program, participants and parents/guardians will be asked to complete an evaluation form telling us about their experience with the program. This information can be used to make program improvements and determine the impact of the group. All information collected will be strictly confidential.

Please apply by April 30th, 2024.

Child Name*

Gender Identity*

Date of Birth*

Date

Age*

Grade*

School*

Parent/Guardian Name*

Email address*

example@example.com

Address*

City*

Postal Code*

Mobile Number*

Why does your child want to be involved in this program?*

Please check any of the following characteristics that describe your child:*

Does your child have any specific medical conditions; allergies or other concerns we should know about? If yes, please describe*

Although you do not have to be involved in any particular way, the following options are available to you:*

Your child will meet his/her mentor at the start of the program. If possible, would you like to be present when they meet the first time?Every child in the program participates in pre-match training. Would you like to receive a copy of the material prior to your child participating?Would you like to receive updates about the progression of the group?

I ACKNOWLEDGE AND CONSENT TO THE FOLLOWING:*

I understand if I drop my child off late, they may not be able to participate in the group that day.I understand a healthy snack will be provided, and I will ensure to inform BBBSCVI of any allergies.I am responsible for getting my child home safely at the end of the each day.

Please indicate how your child will be getting home from the Group Program:*

I, the parent/guardian will be picking picking up my child promptly at 4:45pm at Big Brothers Big Sisters, 2030 Northfield Rd.My child will be taking the bus.My child will walk home when the program ends.Other

Media Consent

We want to know if it's okay for us to take photos and/or videos in which your child is featured or can be seen, to be used in promotion of our programs. Please read through the agreement as seen below. You don't need to consent in order for your child to participate in this program!

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I, the parent/guardian named below, hereby consent to Big Brothers Big Sisters of Canada (National Office) and itsassociated member Big Brothers Big Sisters agencies (Big Brothers Big Sisters of Central Vancouver Island) the use of any photographs, audio and/or videorecordings of my child as taken or produced by media personnel and/or NationalOffice or Local Agency staff at recreational events or match outings, or otherwise authorized by the National President & CEO, local agency President/Executive Director/CEO or Board of Directors, and that this media may be used by Local Agency and/or by the National Office for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the localagency websites and social media, such as Facebook, Instagram, Twitter, etc.). Photographs or video productions may also be shared with community and school partners for program promotion. I further waive any claim which I may have against Big Brothers Big Sisters of Canada and its associated member Big Brothers Big Sisters agencies arising from the use ofsuch photographs, audio and/or video recordings of myself, as aforesaid. This consent and waiver shall remain in effect unless otherwise revoked. *You do not have to consent to the media agreement for your child to participate in the program

Please indicate whether or not you give media consent.*

I hereby give consent.I hereby do not give consent.

Informed Consent (Site-Based Group Program)

I hereby give permission to Big Brothers Big Sisters of Central Vancouver Island (BBBSCVI (the “Agency”)) 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 led by a responsible individual (minimum 15 years old) with my child for the purposes of shared activities, friendship and support. 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 BBBSCVI, 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, with the group facilitator so that my child’s needs may be best met.

I understand that this application is the property of BBBSCVI. I also agree that my child will participate in the Pre-Match Training Program administered by BBBSCVI to be provided prior to participation.

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

I, the parent/guardian, as named below, hereby request Big Brothers Big Sisters services for my child. I give my child permission to participate in one or more group programs offered by Big Brothers Big Sisters. 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.

Today's Date*

Date

Parent/Guardian*

Parent/Guardian (signature)*

Play On – Parent Permission

Arts and Crafts at Big Brothers Big Sisters

Wednesdays 2:30ish – 4:45pm, May 8th – June 12th, 2024)

APPLICATION FORM

PARENTAL/GUARDIAN INVOLVEMENT

Media Consent

Informed Consent (Site-Based Group Program)