Power Up Participant Application
PLEASE READ:
Thank you for your interest in enrolling your child(children) in the Big Brothers Big Sisters Power Up program.

Power Up is a virtual program for school-age children, grades K-12. One hour meetings are held on Zoom every other week throughout the school year and include group activities focused on social and emotional learning exercises. The program will provide homework help as well. Students will be assigned to groups based on their grade level. This is a free program meant to be a fun and engaging way to keep kids connected and supported during the COVID-19 Pandemic.

You MUST fill out a separate form for each child you are enrolling.


10/8/20: At this time we are in the enrollment phase of the program. We will soon have a start date and will email you a calendar and detailed information about your child's Power Up group.
Parent/Guardian Name *
Parent/Guardian Relationship to Child *
Child First Name *
Child Middle Initial *
Child Last Name *
Child's Preferred Nickname
Legal Sex *
Gender Identity (optional)
Child's Date of Birth *
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DD
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Race/Ethnicity *
Required
Parent/Guardian Home Phone Number *
Parent/Guardian Cell Phone Number *
Child Cell Phone Number (if applicable)
Home Address (Street, City, State, Zip) *
Parent/Guardian Email *
Child Email
Child's School *
Child's Grade Level *
What meeting options fit best in you and your child's schedule ( select all that apply) *
Required
How is your child currently attending school? *
PARENT PERMISSION: By submitting this form you are giving permission for: * your child to participate in the Big Brothers Big Sisters Program * your child to complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests * your child to talk with Big Brothers Big Sisters staff about personal safety. Please select yes to confirm your acceptance and understanding. *
CONFIDENTIALITY: By submitting this form you acknowledge understanding that any information you or your child shares throughout the program will be kept confidential, unless disclosure is required by law. Please select yes to confirm your acceptance and understanding. *
WAIVER OF LIABILITY: By submitting this form you release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to yourself as his/her guardian. Please select yes to confirm your acceptance and understanding. *
PROGRAM EXPECTATIONS: By submitting this form you agree to a partnership with our staff to provide the greatest impact in your child's life by encouraging their regular participation in scheduled meetings throughout the school year. You recognize that the biggest impact is made with consistency over time. Please select yes to confirm your partnership. *
MEDIA CONSENT: Do you give permission to allow your child's photograph and name to be connected with the Big Brothers Big Sisters Program and be used in press releases and other promotional advertisements. *
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