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Little_Brother_Little_Sister_Application_Packet_11

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					                  Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                  100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                             856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________


          BBBS Clayton Little Brother Little Sister Application
    To be completed by parent/guardian. All information is kept strictly confidential.


Date of Application ___________                                                            Please place a
                                                                                        picture of child here
                                                                                             if available




Child’s Name ___________________________________________ Gender ____________
Date of Birth ___________________________________________ Age _______________
Social Security # ________________________________________ Race _______________
Mailing Address _____________________________________________________________
City __________________________________________________ Zip ________________
Physical Address (if different) __________________________________________________
Does your child speak and understand English? Yes                 No
If no, what is primary language? ________________________________________________
Name of Parent/Guardian ____________________________________________________
Home Phone ______________________________ E-Mail__________________________
Cell Phone ______________________________ Other Phone _______________________
If someone shares custody of this child please provide their name, relationship to the child, and
phone number_________________________________________________________
Place of Employment ________________________________________________________
Work Phone____________________________ Can you be contacted at work?                           Yes      No
Do you speak and understand English? Yes                 No
If no, what is primary language? ________________________________________________
Name of others living in the home:
       NAME                               AGE                            RELATIONSHIP
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
                 Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                 100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                            856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________

Child’s School __________________________________________ Grade _____________

Teacher ___________________________________________________________________
If child has been seen by Child Study Team or School Counselor please give name and phone
number of counselor or Child Study Team
__________________________________________________________________
If child is classified, explain how _______________________________________________
If child is dealing with any behavior problems, please explain
__________________________________________________________________________
If child is involved in counseling/therapy, please give name and phone number of therapist or
counselor __________________________________________ Phone __________________
If child has ever been arrested or involved with police/juvenile authorities, please explain
___________________________________________________________________________
___________________________________________________________________________
If your family is involved with DYFS, please give caseworker’s name and phone number
___________________________________________________________________________
Does this child have an incarcerated parent?
___________________________________________________________________________
Please list any other agencies involved with your child/family
_____________________________________________________________________________
_________________________________________________________________________
Does your child respond well in group situations? Yes              No
Does your child respond well in one-to-one situations? Yes                No
Does your child want a Big Brother/Big Sister? Yes              No
What kind of activities would your child like to do with a Big Brother or Big Sister?
___________________________________________________________________________
___________________________________________________________________________
How do you feel it would be beneficial? __________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
  Please feel free to provide us with any additional information you feel may be helpful on the
          back of this form and return completed application in the enclosed envelope.
Parent/Guardian Signature: ___________________________________________________
                   Thank you for your interest in Big Brothers Big Sisters!
                  Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                  100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                             856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________

                         BBBS Clayton Match Policy


Please read the following policy, which pertains to the parent or
guardian and child very carefully before signing your name to this
application. Thank you.

I understand that Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties is
not obligated to assign or actively seek to assign a volunteer to any child. I also understand that
Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties makes no warrantee,
guarantee or other commitment either stated or implied a impact of a match upon any of the
parties involved whether emotional, physiological, spiritual, or physical, or other than the
normal guarantee of any individual that the best judgment and concern will be applied in
dealing with the human personality.


In recognition thereof, I hereby agree to hold free of liability Big Brothers Big Sisters of
Burlington, Camden and Gloucester Counties and Big Brother Big Sisters of America and all
agents and representatives thereof, in the event of any unfortunate results or developments
occurring as a part of their efforts on my child’s behalf.



Parent/Guardian Signature: _____________________________                                Date: _____________


                           FOR QUESTIONS PLEASE CONTACT:
                             Tracy L. Moore @ 881-8700 ext.03053
                                 Clayton Program Coordinator
                            Victoria M. Gould @ 881-8700 ext. 3290
                                     BBBS Case Manager


                            PLEASE RETURN ALL FORMS TO:
                    Clayton Big Brother Big Sisters Mentoring Program
                                  300 W. Chestnut Street
                                Clayton, New Jersey 08312
                Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                           856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________



         BBBS Clayton Little Brother Little Sister Application
      To be completed by Child/Youth. All information is kept strictly confidential.



PLEASE PRINT CLEARLY


Your Name: ___________________________________                        Age: ______________________


Favorite subject in school: _____________________________________________________


Least favorite subject: ________________________________________________________


Activities you are involved in at school: __________________________________________
___________________________________________________________________________


What would you like to do when you get older? ____________________________________


What do you like to do on the weekends or in your spare time? ________________________
___________________________________________________________________________


What are your favorite hobbies or activities? ______________________________________
___________________________________________________________________________


Why do you want a Big Brother or Big Sister? _____________________________________
___________________________________________________________________________


What should we tell your Big Brother or Big Sister about you? ________________________
___________________________________________________________________________
___________________________________________________________________________
                 Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                 100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                            856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________




Little Application (Cont.)
Checklist: Please check if you participate in the listed activity, would like to
learn to do a certain activity, or have no interest in an activity.


Activity                  Participate In                 Would like to learn           No Interest
Camping/Hiking
Board Games
Video Games
Basketball
Baseball/Softball
Football
Soccer
Fishing
Bicycling
Cheerleading
Movies
Mini Golf
Cars/Trucks
Music
Swimming
Drawing/Painting
Computers
Reading
Cooking/Baking
Shopping
Skating/Rollerblading
                   Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                   100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                              856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________



                    BBBS Clayton Income Verification Form

Dear Parent:


Please complete this form to verify your household income. Several of our funding sources ask the
income range of the children we are serving in our program. We use the information provided here to
track that information. Please note that your income level does not impact your level of service with our
agency, we ask that this information only for reporting purposes. When reporting these statistics we will
only report the total numbers of all clients, we will not be reporting individual information. This
information, like all other information we collect, will remain confidential.
Are you a single parent?   Yes       No
Does your child receive a free or reduced lunch?               Yes        No
How many children are in your household? _______
Please check off your annual household income:
_____ Less than $10,000 per year
_____ $10,000 to $14,999 per year
_____ $15,000 to $19,999 per year
_____ $20,000 to $24,999 per year
_____ $25,000 to $29,999per year
_____ $30,000 to $34,999 per year
_____ $35,000 to $39,999 per year
_____ $40,000 to $44,999 per year
_____ $45,000 to $49,999 per year
_____ $50,000 to $59,999 per year
_____ $60,000 to $74,999 per year
_____ $75,000 to $99,999 per year
_____ $100,000 to $124,999 per year
_____ $125,000 to $149,999 per year
_____ $150,000 to $199,999 per year
_____ $200,000 or more per year


Print your Name: ____________________________________________________________
Sign your Name: ____________________________________________________________
Date: ___________________
                  Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                  100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                             856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________

                      BBBS Clayton Confidentiality Policy
Access to Confidential Records

In order for Big Brothers Big Sisters of Burlington County to provide a responsible and
professional service to clients, it is necessary for volunteers, clients and parents/guardians of
clients to be asked to divulge extensive personal information about themselves and their
families. The agency respects the confidentiality of client and volunteer records and, with the
exception of situations listed below, will share information about clients and volunteers only
among the agency professional staff. The right to confidentially applies not only to written
records, but extends to video, film, photos, or use of the client’s or volunteer’s name in agency
publications.

All records are considered the property of the agency, not the agency workers, clients or
volunteers themselves. In order to provide a service, which is in the best interest of the children
served by the program, information from outside sources, including confidential references
must be assessed along with information gained from the clients or volunteers themselves.
Records are not available for review by the clients, parents/guardians or volunteers. Volunteers
and parents/guardians of clients shall be provided, at the time of the application, a copy of this
statement on confidentiality along with the exceptions, which define the limits of
confidentiality. Volunteers and parents/guardians of clients shall sign a statement that he/she
has read and understands the agency policy on confidentiality and agrees to program
participation under the guidelines it sets forth.

Limits of Confidentiality

1. Information will be released to other individuals or organizations only upon presentation of
   an authorized “consent to release information” form appropriately signed by the
   parent/guardian of client or volunteer.

2. Identifying information regarding clients and volunteers may be used in agency publications
   or promotional materials if the parent/guardian of client or volunteers has given permission.

3. For the purpose of the evaluation, audit, or accreditation, certain outside bodies such as Big
   Brothers Big Sisters of America may have access to client and volunteer records. These
   outside organizations shall be required to respect the agency policy on confidentiality.
   Outside parties shall be required to use information only for the purpose(s) stated. Known
   violations of agency confidentiality policy will be reported to the supervisor or the
   individual involved and appropriate disciplinary action shall be requested.

4. Information shall be only provided to law enforcement officials or the courts pursuant to a
   valid and enforceable subpoena.

5. Information shall be provided to an agency’s legal counsel in the event of litigation or
   potential litigation involving the agency, such information is considered privileged
   information, and its confidentiality is protected by law.
                  Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                  100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                             856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________

6. NJ State law mandates that suspected child abuse be reported to the NJ Department of
   Human Services, Division of Youth and Family Services.

7. If the agency has reason to believe that a client (or family member of the client) or volunteer
   may be dangerous to himself or herself or others, necessary steps will be taken to protect the
   appropriate party. This may include a medical referral or a report to the local law
   enforcement authorities.

8. You will be given basic and general information about your child’s potential Big Brother/
   Big Sister. The same type of general information about you will be shared with your
   potential match partner upon match proposal.

I have read and understand the above document stating the agency policy with respect to
confidentiality of client and volunteer records. I agree to program participation under the
conditions it sets forth.


Parent/Guardian Signature: ____________________________                            Date: ________________



                        Consent to Share and Agreement to Protect the
                            Confidentiality of Match Information

I agree that a summary of information, prepared by Big Brothers Big Sisters of Burlington,
Camden and Gloucester Counties will be shared with my potential Big Brother/Big Sister. I
understand that no identifying information will be given until after both parties agree on the
Match.

The information to be shared may include: age, race, religion, interests, hobbies, family living
information, and expectations for match participation.

I agree to keep all the information discussed with me regarding the individuals involved in the
Match confidential. I will not discuss this information with anyone other than the assigned
professional staff of Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties.

Parent/Guardian Signature: _____________________________                           Date: ________________
               Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                               100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                          856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________

            BBBS CLAYTON MENTORING PROGRAM
            AUTHORIZATION FOR RELEASE OF
               CONFIDENTIAL INFORMATION




I understand that it will be necessary for Big Brothers Big Sisters of
Burlington, Camden, and Gloucester Counties to investigate my child’s
background.

I hereby give my consent for this information exchange and authorize
you to release information requested by this agency, if, in your opinion
you feel this information could prove beneficial in helping my child.

Dated this ___________ day of ______________________, (year) __________________

Signature of
Parent/Guardian___________________________________________
                  Big Brothers Big Sisters of Burlington, Camden and Gloucester Counties
                                  100 Dobbs Lane Suite 202, Cherry Hill, NJ 08034
                             856.616.2340 office * www.bbbsbcg.org * 856.616.2337 fax
___________________________________________________________________________



              BBBS CLAYTON MEDIA RELEASE


The undersigned hereby consents to and authorizes Big Brothers Big Sisters of Burlington,
Camden and Gloucester Counties the right to use the name of, photographs of, and statements
made by the undersigned in news releases and publicity items in support of the commercial and
non-commercial activities, including fund raising activities, of Big Brothers/Big Sisters of
Burlington, Camden and Gloucester Counties.

The undersigned acknowledges that no remuneration or compensation shall be paid by Big
Brothers/Big Sisters of Burlington, Camden and Gloucester Counties in return for this consent
or authorization, on the use of, or publication of, the name, photograph or statements of the
undersigned.

This release shall continue in full force and effect until withdrawn in writing by the
undersigned.


Signature                                                                                  __

Signature of Guardian
(if above is a minor)                                                                      __

Name (please print)                                                                        __

Address                                                                                    __

                                                                                           __

Date

				
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