In School Mentoring Application Form - Big Brothers Big Sisters of Ottawa

Little Application Form and Consent

* denotes that answers to these questions are mandatory

Name of School

Name of Teacher/School Contact

Grade*

Personal Information

Child’s Name*

Given Last

Date of Birth (mm/dd/yyyy)*

MM slash DD slash YYYY

Gender*

Please specify.

Address*

Street Address City Province Postal Code

Telephone*

Cell

Home (N/A if none)

Alternate (N/A if none)

Parent’s Email Address*

Enter Email Confirm Email

Languages spoken*

English

French

Other

Other languages spoken:

Emergency Contact*

Full Name

Relationship

Telephone

What is the mentee’s country of origin?*

What is the mentee’s immigration status:*

How long has the mentee been in Canada?*

Is the mentee?

Please specify.

Is the mentee francophone?

Yes

Is the mentee a part of the 2SLGBTQIA+ community?

Yes

Is the mentee living in care (e.g. Foster Care, Kinship, Adoption)?

Yes

Does the mentee live in a rural area?

Yes

Does the mentee have disabilities (e.g. Vision, Hearing, Learning, Developmental or Cognitive, Mobility, Speech/Language, Coordination) ?

Yes

Please specify.

Primary Caregiver

Name*

Given Last

Tel. (Cell)*

Tel. (Work)

Relationship to Child*

Getting to Know Your Child

This information will help us begin to understand your child which will help us find a good mentor.

Why does your child want to be a mentor?*

Please check any of the following characteristics that describe your child:*

Friendly

Shy

Outgoing

Withdrawn

Active

Helpful

Please share other characteristics of the child.

If not listed in choices above.

Please check any of the following that describes your childs interests:*

Cooking

Music

Board/Card Games

Animals

Arts/Crafts

Reading Books

Building (i.e. LEGO)

Movies/TV

Sports

Computers

Video Games

Talking

Does your child have any specific medical conditions, allergies or other concerns we should know about?*

Yes

Please describe:

What classes would you rather your child not miss?*

Choosing a Mentor

Is there anything you would like us to be aware of that would assist us in finding the right mentor for your child?*

Yes

Please describe:

Your Involvement

Although you do not have to be involved in any particular way, the following options are available to you. If you would like to be involved in some other way, please contact the Big Brothers Big Sisters office.

Your child will meet his/her mentor during the school day. If possible, would you like to be present when they meet the first time?*

Yes

Every child in the program participates in pre-match training. Would you like to receive a copy of the material prior to your child participating?*

Yes

Would you like to receive updates about the mentoring relationship?*

Yes

Pre-Match Training

Pre-Match Training is mandatory for all Littles participating in BBBSO programs. The Ontario Curriculum for Health and Physical Education and the Ontario Curriculum for Social Studies fulfills part of the requirement of Pre-Match Training as per Big Brothers Big Sisters Canada National Standards. In order for your child to participate in the school-based mentoring program, he/she must complete an orientation that will be delivered by the School Liaison. The orientation will review:

program guidelines and goals
what it means to be a Little and the role of the Big
healthy relationship development
establishing and respecting both physical and social boundaries

Consent*

I consent to my child participating in an orientation session to be delivered by the School Liaison.*

Consent*

I consent to my child participating in a program evaluation at the end of the program.*

Consent*

I agree that the statements made in this application are true and correct and have been given freely.*

Name

This field is for validation purposes and should be left unchanged.

Little Application Form and Consent

Personal Information

Primary Caregiver

Getting to Know Your Child

Choosing a Mentor

Your Involvement

Pre-Match Training

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