Consent Form (Page 2): School Based Mentoring Virtual 1:1

The Virtual Mentoring 1:1 program will support Children in a social emotional capacity.  Mentors in this program are asked to connect on line once a week with their mentee for up to a one year commitment.  We anticipate through one to one mentoring children and youth will experience developmental relationships evidenced by the following elements: their mentor challenges them to grow, provides support, shares power, and children and youth know they matter to their mentor.

You have referred your child to participate in the BGCBigs Mentoring Program. It is a community service program designed to assist your son/daughter to reach his/her fullest potential and to assist in the enhancement of their Social, emotional learning skills.

CONFIDENTIALITY and INFORMED CONSENT – FOR PROVISION OF SERVICE

INFORMED CONSENT: I hereby give permission to Edmonton BGCBigs to make available their service to my child.  It is my understanding that the intention of the Agency is to match my child, in an individual or group program, with 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 BGCBIGS, 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 Edmonton BGCBigs, 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 Edmonton BGCBigs.  I also agree that my child will participate in the Pre- Match Training Program administered by the agency staff or a school representative.

As the Parent/Legal Guardian, or the Referring Individual I authorize Boys and Girls Club Big Brothers Big Sisters of Edmonton and Area to use the information provided within their agency. I am consenting to receiving programs and services for my family, or contact to be made with this family.  I agree that the information I have provided is true to the best of my knowledge. I acknowledge that some information will need to be shared with funding bodies as part of our agreement with municipal, provincial and federal funding sources.

  • You grant permission for your son/daughter to participate in the BGCBigs Mentoring Program.
  • This consent form is effective for the duration your child’s involvement of the BGCBigs Mentoring program.
  • Your child will not have contact with his/her mentor outside of program hours. If such contact is initiated, the match may be ended by the agency.
  • You and your child will be asked to complete program surveys and evaluations as part of regular follow-up and match monitoring of the program.
  • Your child’s teacher may be asked to also participate in the completion of surveys for evaluation information as requested by the BGCBigs
  • You understand that you have the right to examine your child’s file, and any child at 12 years of age has this same right. Such an examination may be requested through the Principal of your child’s school (if applicable) or your program facilitator.
  • You agree to your child participating in a Pre-Match Program offered by the school and/or BGCBigs before your child is matched with a Mentor. The Pre-match training program is designed to cover the following areas:
    • *understanding of what mentoring is, boundaries and stages of the mentoring relationship, including endings; safe and healthy relationships
    • *Communication enhancement – including keep and speak secrets
    • *role of your program facilitator.
  • You release BGCBigs and   of all responsibilities and liabilities in connection to the services provided in good faith to your child.

INFORMED CONSENT FOR PROVISION OF SERVICE:

I, , parent/guardian of , 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.

CONFIDENTIALITY: All individuals in a position of trust within the agency are required to sign a privacy/confidentiality agreement.   This includes staff, family and volunteers.   It is important to understand that information will be shared with other staff only as needed for service to your child or family.    Care will be taken that information to any involved professional outside of the agency is only released with the signed consent of the family except in the case of concern of child abuse or neglect, where staff are required by law to inform the proper authorities, which could result in the disclosure of confidential  information.

CONFIDENTIALITY AGREEMENT

I, , parent/guardian of , have read the BGCBigs statement on confidentiality and do understand and agree.

CONSENT FOR AUDIO / VISUAL RECORDING

On occasion, your child’s photo may be taken in relation to their participation with BGCBigs.  These photos may be used in promotional materials and advertisement 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.

I, , parent/guardian of provide consent that my child can be photographed, videotaped or recorded in conjunction with programs of BGCBigs and further agree that materials produced as a result are the property of BGCBigs (indicate yes or no below).