Consent Form (Page 2): School Based Tutoring Virtual

Virtual Tutoring/Reading program is designed to assist your child to support their academic needs through some homework support for the remainder of this school year. Children and youth will be matched with a Mentor and are asked to connect on line for 45-60 minutes once a week with their mentee for the current school year. Through virtual tutoring, children and youth receive academic support related to math, science, literacy and any other related subject.

Over time, this helps children and youth meaningfully improve their academic skills and become more confident in these abilities.

They will meet once a week or more often if needed to review and work through some of your child’s academic needs. We will establish the best amount of time at the introduction meeting.  We will have staff check in on how the match is going at three points through the school year.

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.

  • Parents must grant specific permission for their children to participate in the BGCBigs Virtual Tutoring/Reading Program.
  • Contact between match participants will occur via approved and agreed upon platform(s) Mentor City.
  • An introduction video conference or phone call will be coordinated by the Facilitator, and guidelines for future contact will be outlined for the mentors and mentees.
  • Match participants, including parent and child must agree to take part in regular follow-up and match monitoring with the Facilitator.
  • Responsibility for the oversight of children’s contact with their mentor will be in the parent’s hands and any concerns identified must be communicated to the Facilitator.
  • Parents release BGCBigs and your child’s school 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).