Virtual GO GIRLS Informed Consent

Big Brothers Big Sisters of Kawartha Lakes - Haliburton respects your privacy and adheres to Ontario personal information privacy legislation (FIPPA). The information provided will be used to create a confidential client file to assist in program delivery for our virtual groups. Please contact BBBSKLH at 705 324 6800 with any questions/concerns.
  • CHILD/YOUTH INFORMATION

  • PARENT/GUARDIAN INFORMATION

  • Provide if youth will be using their own email address to access Zoom link for virtual program.
  • PROGRAM CONSENT

  • Any photographs or video productions taken of children or youth by agency staff at recreational events or match outings, or otherwise authorized by the Executive Director or Board of Directors, may be used by the agency for the purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners for program promotion. My child’s FIRST name only, general personal circumstances, and general information about their match may be included.
  • I hereby give permission to BIG BROTHERS BIG SISTERS OF KAWARTHA LAKES - HALIBURTON to make available their service to my child. It is my understanding that the intention of the Agency is to offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. In consideration for this service and other valuable consideration provided to my child by BIG BROTHERS BIG SISTERS OF KAWARTHA LAKES - HALIBURTON, 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 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 further agree that information about my child may be shared, at the discretion of BIG BROTHERS BIG SISTERS OF KAWARTHA LAKES - HALIBURTON, with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of BIG BROTHERS BIG SISTERS OF KAWARTHA LAKES - HALIBURTON. I also agree that my child will participate in the Pre- Match Training Program administered by BIG BROTHERS BIG SISTERS OF KAWARTHA LAKES - HALIBURTON. I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY CHECKING "YES" TO THIS AGREEMENT, I ACKNOWLEDGE THAT: I am the parent/guardian of the child mentioned above, and I hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by BIG BROTHERS BIG SISTERS OF KAWARTHA LAKES - HALIBURTON. 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.
  • By checking 'Yes' below you are providing your consent for your child to engage in the Online Go Girls Program, and have virtual contact through Zoom with up to six other program participants and up to 2 program facilitators for the duration of the program. The group will be monitored by Big Brothers Big Sisters Staff member at all times. You can find Zoom's privacy policy here: https://zoom.us/privacy I understand that: · as the parent/guardian, the group will adhere to the following rules which will be reinforced in the first few minutes of the meeting: 1) No sharing of personal contact information will be a highlighted rule 2) No screen sharing between participants 3) No private chats between participants. Any communication between your daughter and other program participants that takes place outside of the Go Girls online platform and/or service-delivery dates cannot be monitored by the Mentoring Coordinator and should be approved and monitored at your discretion. I agree to: 1) Provide continued supervision and support, checking in with my child following each group meeting and throughout the six weeks, to determine how my child is responding to the program. 2) Try to ensure group privacy by not reading the chat room conversations. 3) Contact BBBSKLH immediately should any concerns arise related to my child’s participation in this program. 4) Contact the Mentoring Coordinator if I or my child need support to access and/or adjust to the online Go Girls program. 5) Do my best to support my child’s participation in the weekly group meetings.