We Are Kids (WAK) Youth After School Program - Big Brothers Big Sisters of Lanark County

Name*

First Last

Youth's Phone Number

Youth's Email

Date of Birth*

preferred pronouns

Child's School*

Current School Involvement

In School Learning
Distance / Virtual Learning

Is your youth permitted to go home on their own?*

Yes
No

Parent / Guardian's Name*

Prefix First Last

Relationship to Child

Mother
Father
Other

If answered other to above please specify

Parent / Guardian Phone Number*

Parent / Guardian Email

Family Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does your child have any medical or behavioral needs that we should be aware of?*

Yes
No

We realize that this information can be of a sensitive nature and it will be treated with confidence and respect.

If yes, please provide details.

Is your youth on any medication?*

Is there any other information you would like the Facilitators to know about your youth?

Ex. religious or cultural views, stressors, other existing issues?

Does your youth generally get along with their peers?

Has your youth experienced:

Select All
Bullying
Violence
Behavioural Issues
Smoking/Vaping
Drug Use
Alcohol Use

Media Consent*

YES, I give Media Consent
NO, I do not give Media Consent

From time to time, photo's of youth are taken during program hours and shared on our social media pages. Additionally, their are times when group photos of youth and staff/volunteers are used to help us in our recruitment of volunteers. This includes use in community newspapers, photo albums, bulletin boards or being displayed in the office. This could include other promotional purposes such as for a slide or video show, promotional material included in media/information kits, or newsletters. This consent form is required to enable us to use these photos. Please indicate below whether you do or do not give consent. You cooperation is appreciated.

Informed Consent*

WAK (we are kids) Youth Program is a partnership program developed by Big Brothers Big Sisters of Lanark County (BBBSLC), Town of Smiths Falls and YAK Youth Services. The program is developed and facilitated by BBBSLC. I hereby give permission for my youth to attend WAK Youth Program. It is my understanding that the intention of this program is to offer my youth the opportunity to participate in group program that is lead by fully screened and trained staff and volunteers. In consideration for this service and other valuable consideration provided to my child by BBBSLC, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my youth. 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 youth 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 BBBSLC, with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of BBBSLC.

Parent/Guardian Name/Signature*

First Last

I hereby give permission for my youth to participate in the WAK Youth Program by BBBSLC. By typing my name and submitting this form I acknowledge that I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my Youth.

Today's Date*