Online Youth Application

Thank you for your interest in Big Brothers Big Sisters. Please complete the application below and click the submit button when done. A Big Brothers Big Sisters staff member will follow up with you shortly.

You may also fill out a paper application and email to bbbs.info@bbbscentralcarolinas.org or fax to 704-910-5633; or hand deliver or mail to 3801 E. Independence Blvd, Charlotte, NC, 28205.

 

Youth Application

Community-based youth application and parental permission form.
  • Please provide name and phone number
    Please check all that apply
    Total income of the adults the child lives with
  • PARENTAL PERMISSION

    By typing my name 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 transport my child to events and match activities;
    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 in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests;
    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 and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must 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 do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating 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 his/her guardian. 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.

  • ACCIDENT COVERAGE STATEMENT

    Big Brothers Big Sisters of Central Carolinas provides limited automobile insurance coverage for program participants (Big-volunteer/Little-youth). The following sets forth those limitations.

    In the event that a Little Brother/Little Sister is involved in an automobile accident while transported by an active Big volunteer, BBBS has a comprehensive insurance program that provides coverage in the event the Big is at fault. If, however, the Big is not at-fault, the person(s) designated at-fault, or his or her insurance company, would be liable for damages or injuries as a result of said accident. Should the person(s) at-fault not have insurance or not have sufficient insurance to compensate for the injury suffered as a result of the accident, BBBS’s insurance will not cover the accident and responsibility for any expenses resulting from the accident may fall on the parent/child or their insurance company.

    My signature below acknowledges that I have read and understood the above information regarding insurance coverage and that I hereby release BBBS from any liability for such incidents not covered by BBBS’s insurance.
  • PARENTAL/GUARDIAN PUBLICITY CONSENT FORM

    I do hereby authorize Big Brothers Big Sisters of Central Carolinas to use my or my child’s image and voice, including photos and videos, for publicity purposes to promote the Big Brothers Big Sisters of Central Carolinas program. The images/voices may be used in various promotional materials (such as our website), news media publicity, Facebook, and Twitter.

    It is my understanding that first names, images/voices may be used by BBBSGC corporate partners.

    I agree that there will be no compensation whatsoever for this participation or for the use of resulting materials by Big Brothers Big Sisters.

    Big Brothers Big Sisters of Central Carolinas unconditionally releases me from all liabilities or claims that may result from the existence and use of any such materials.
  • This will serve as a signature
    First and last names may be used
  • MEDICAL RELEASE FORM: AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR

    I/we hereby state that I am (we are) parent/legal guardian of:
  • Parent, please read in full before signing!

    I grant the above mentioned adult to have temporary custody and responsibility for the care of the above-name minor, to consent to any X-rays, physical examination, medication, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or surgeon when the need for such treatment is immediate and only after efforts have been made to contact me/us are unsuccessful. I/We will not hold the temporary custodian, physician, or hospital providing care responsible for action taken in good faith in presenting the above named child for care or providing examination. This authorization shall be valid when my child is in the temporary custody and care of the Big Brother or Big Sister or any BBBS agency representative or in attendant at any Big Brothers Big Sisters Group activity.