Informed Consent & Media Release

I hereby make formal application to Big Brothers Big Sisters of Eastern Newfoundland to make available their service to my child. It is my understanding that the intention of the Agency is to match a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), with my child for the purposes of shared activities, friendship and support. I understand that all efforts will be made to select a Mentor who is compatible with my child. In consideration for this service and other valuable consideration provided to my child by Big Brothers Big Sisters of Eastern Newfoundland, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. 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 consent to Big Brothers Big Sisters of Eastern Newfoundland contacting any referring professionals involved with my family to obtain information for the purpose of assessing my application for a Mentor. I further agree that all or part of the information herein may be shared, at the discretion of Big Brothers Big Sisters of Eastern Newfoundland, with my child’s Mentor, and/or with the referring professional, so that my child’s needs in a Mentoring relationship may be best met. I understand that the collection of personal information about me or my child will be held in strict confidence and is to be used solely for the purposes of administering the program. I understand that I am under no obligation to accept a Mentor for my child, that the Agency is under no obligation to provide my child with a Mentor and that this application is the property of Big Brothers Big Sisters of Eastern Newfoundland. I also agree that I and my child will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of Eastern Newfoundland.*

By checking this box I agree to the statement of consent

I have read and understand this agreement. By signing this agreement, I acknowledge that as the parent/guardian, I hereby request Big Brothers Big Sisters services for my child. I give the agency my consent to assign a Mentor to my child. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child.

Parent/Guardian*

First Last

Child Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Date*

Informed Consent (Community-Based) – Parent/Guardian

Note: Release to share information with other professionals will expire within one year of the above date