I hereby make formal application to Big Brothers Big Sisters of Western North Carolina, Inc., a non-profit North Carolina corporation, to make available the services of Big Brothers Big Sisters to my child, and, if possible, assign to him/her a competent adult volunteer. I hereby release Big Brothers Big Sisters of Western North Carolina, Inc. of all responsibilities and liabilities in connection therein.

At such time that my child is matched with a volunteer, I understand that Big Brothers Big Sisters staff will need to speak with me and my child on a regular basis about the relationship. The purposes of these contacts are to monitor the development of the mentoring relationship and the safety of my child.

I give permission for:

- BBBS to request information from any agency or individual (such as school, after-school, counselor, etc.) regarding my child that is deemed necessary by Big Brothers Big Sisters of WNC. This information will be held in the strictest confidence and will assist Big Brothers Big Sisters staff in making and supervising a match between my child and a volunteer.

- My child to complete a questionnaire containing questions about peer relationships, feelings about school, grades, educational expectations, parental relationships and attitudes toward risky behaviors

- My child to talk with a BBBS staff person about personal safety.

- The school to share information with BBBS and/or the mentor for purposes to helping my child succeed in school. BBBS staff and/or the mentor can visit the school for lunch or other purposes to support my child’s school success.

CONFIDENTIALITY POLICY

Big Brothers Big Sisters of WNC respects the confidentiality of client and volunteer records and, with the 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 property of the staff, clients, or volunteers.

Records are not available for review by the clients or volunteers.

Information will be released to non-BBBS organizations or other individuals only with the client’s or volunteer's written consent.
Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteer request otherwise.

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

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

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

Information shall be provided to an agency's legal counsel in the event of litigation or potential litigation involving the agency.
State law mandates that suspected child abuse or neglect be reported to the Department of Social Services.

If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities.

At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. Information about the volunteer that is shared with the parent/guardian may include such items as: age, sex, race, religion, interests, hobbies, marriage, family status, sexual orientation, living situation, etc. Information about the child that is shared with the volunteer may include such items as age, sex, race, religion, interests, hobbies, family situation, etc.

I agree to program participation under the above conditions.