SCHOOL REFERRALS School Program Referrals Please complete ONLY as a TLDSB referral, on behalf of a student. Please ensure parent/guardian consent prior to completing as we will need to contact parent/guardian throughout program. This form is designed for In-School Mentoring (ISM) or GO GIRLS! group programming. Programs will start in January. ISM will run from January until April/May, for matches to meet 1 hour/week virtually. GO GIRLS! will run for 6 to 8 weeks, depending on arranged schedule, beginning in January. Dates to be confirmed. GO GIRLS! is designed for girls in grades 6 to 8. SCHOOL REFERRAL INFOFull Name*School*Position at School:*Phone Number*Email*PARENT/GUARDIAN INFORMATIONParent/Guardian Name*Phone Number*Address*City*Postal Code*STUDENT INFORMATIONStudent's Name*Date of Birth*School*Grade*Child/Youth's Gender*FemaleMaleNon-binary/third genderPrefer not to sayPlease select any of the following characteristics to describe the student::* Friendly Shy Outgoing Withdrawn Active Helpful Quiet The child/youth is...*in a single parent familyin a dual parent familyin a foster or adoptive familyin another type of familyReason for referral:*Please describe any mental, behavioural or physical concerns the child/youth experiences:*(eg. ADHD, Asthma, Autism Spectrum Disorder, Fetal Alcohol Spectrum Disorder, Learning Disabilities, ODD, etc.)Please list any food allergies the student has:*AVAILABILITYBoth programs will begin in January 2021. Please select preferred time(s) for child to participate in either a group or a 1:1 match:* During school hours (still virtual, and needs supervision from school) Weekday afternoons (afterschool) Weekday evenings Saturday morning Please indicate the student's current school enrolment:* Online Learning that will transfer to In-Class Learning as per government guidelines (physically attending school) Synchronous Learning (online/distance learning that happens in real time, with set log-in times and a class schedule) Asynchronous Learning (paper learning; learning not occuring with real time interaction; students completing assignments with assigned deadlines that reflects their schedules) Please indicate program of interest(s):* In-School Mentoring GO GIRLS! PROGRAM REQUIREMENTSBoth ISM and GO GIRLS will be run virtually using programs such as Zoom, Google Meets, etc.. These programs are video applications that can be used on smart phones, tablets, and computers. The virtual link will be secure and private. More information will be provided once group spot is confirmed. Please READ and select the following to participate in either GO GIRLS and/or In-School Mentoring:* The student has a device equipped with a camera. The student wants to participate in GO GIRLS/In-School Mentoring Parent/Guardian is aware and anticipates communication from Big Brothers Big Sisters regarding match/group involvement Facebook Twitter Google+ LinkedIn
