Big Futures

BIG FUTURES MENTEE APPLICATION

ALL THE INFORMATION YOU PROVIDE WILL BE KEPT CONFIDENTIAL AND WILL BE USED BY THIS AGENCY ONLY AS SET FORTH IN OUR CONFIDENTIALITY POLICY.

PLEASE ANSWER ALL OUR QUESTIONS TO THE BEST OF YOUR ABILITY SO THAT WE CAN BEST SERVE YOUR NEEDS.

BIG BROTHERS BIG SISTERS OF LICKING & PERRY COUNTIES ADMINISTERS ITS SERVICES INA MANNER THAT DOES NOT DISCRIMINATE.

CONSENT FOR SERVICES: I hereby request Big Brothers Big Sisters of Licking & Perry Counties, a non-profit organization, to continue make available the services of BIG BROTHERS BIG SISTERS to myself, and volunteer community memebers, and agency staff. I give my consent for myself participate in all assessment and evaluation services, to cooperate and assist in all planning activities, and to receive all services as deemed necessary by Big Brothers Big Sisters of Licking & Perry Counties (“Agency”). I consent to completing a questionnaire containing questions about school, home life, personal interests and future plans. I hereby knowingly release and hold harmless Big Brothers Big Sisters of Licking & Perry Counties and their nominees, assignees and designees from liability for any damages incurred due to any injuries sustained by myself as a result of my participation in any Agency sponsored activities.
 
This authorization shall be effective and continually in force, to the extent permitted by law, from the date of this authorization until revoked by myself or the parent/guardian (if under 18) with written notice, or Successor Authorization, provided by BBBS, is executed. 
 
I have read and understand the contents of Consent for Services.

Mentee Confidentiality Policy

Big Brothers Big Sisters of Licking & Perry Counties respects the confidentiality of client and volunteer records, and withthe exception of situations listed below, shares information about clients and volunteers only among the agency professional staff. All records are considered the property of the agency and not the agency workers or clients or volunteers themselves. Records are not available for review by the clients or volunteers.

1. Information will be released to other individuals with non-BBBS organizations only with the client orvolunteer’s written consent.

2. Identifying information regarding clients and volunteers may be used in agency publications or promotionalmaterials unless the client or volunteer requests otherwise.

3. For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board ofDirectors, certain outside bodies such as Big Brothers Big Sisters of America may have access to client andvolunteer records.

4. Members of the Board of Directors or evaluators appointed by the Board have access to client files upon theauthorization of the Board of Directors.

5. Information shall only be provided to law enforcement officials or the courts pursuant to a valid andenforceable subpoena.
 
6. Information shall be provided to an agency’s legal counsel in the event of litigation or potential litigationinvolving the agency.
 
7. State law mandates that suspected child abuse be reported to the appropriate authorities(Newark City Police Department or Licking County Sheriffs Office). *Our staff members are mandated bylaw to report suspected or known instances of child abuse or neglect.
 
8. If an agency worker receives information indicating that a client or volunteer may be dangerous to himselfor herself or to others, necessary steps may be taken to protect the appropriate party. This may include amedical referral or report to the local law enforcement authorities.
 
9. Throughout the course of delivering program services, information is shared between the match parties.The information about the volunteer may include such items as: age, sex, race, religion, interests, hobbies,marriage, family status, sexual orientation, living situation, etc. Information about the youth may includesuch items as age, sex, race, religion, interests, hobbies, family situation, etc.
 
10. Confidentiality policy is applicable to all forms of social media including but not limited to blogs, Twitter,Wiki, chat rooms, forums, and online social networking sites such as LinkedIn, Facebook, and Instagram, andany other form of online publishing or discussion, whether such media exists now or in the future.Volunteers must keep all forms of social media set to private and any sharing of information must be ageappropriate for the youth to view.