Authorization For Release of Confidential Information

This release of information form will be used to check with the school about your child's performance and behavior. Kindly sign by the X and return with the application. If this form is not returned signed, we cannot proceed with your application for the Big Brother or Big Sister.

We need information about your child so that we can determine, with your help, how Big Brothers Big Sisters of Coastal & Northern New Jersey can best help him/her. Any information provided by you or other agencies will be kept completely confidential. If you have any questions, please contact our office.

Release of Information

To provide service to your son/daughter, it is important for us to know all about him/her.

Please sign the following statement:

I grant permission to any school to allow my son/daughter to meet with a worker from Big Brothers Big Sisters of Coastal & Northern New Jersey and to release any information regarding myself or my children to Big Brothers Big Sisters of Coastal & Northern New Jersey. This release also applies to any physician, welfare or social agency or hospital.

Parent/Guardian Statement of Understanding

In submitting this application to Big Brothers Big Sisters of Coastal & Northern New Jersey (BBBSCNNJ) for my child, I understand that:

• If accepted, I will abide by the ground rules and policies of BBBSCNNJ including no overnight visits between Bigs and Littles.
• The information on this application is true to the best of my knowledge. Also, I have not withheld any information regarding my child's health, personality, or behavior which, if later revealed, is likely to have a significant adverse effect on the mentoring relationship.
• BBBSCNNJ does not discriminate nor exclude children or volunteers on the basis of race, religion, natural origin, gender, sexual orientation, veteran status, disability or marital status.
• Acceptance into the program will be determined by the BBBSCNNJ staff based on program/agency criteria and information obtained from the application, interview, and any other relevant sources.
• If accepted, there is no guarantee that a Big Brother or Big Sister for my child will be identified.
• If a potential Big Brother/Big Sister does become available, I will be given general information about him/her before any match is made. This information will be gathered from the volunteer interview. Only the information determined to be pertinent by the case manager will be shared.
• I am in no way obligated to accept any proposed Big Brother or Big Sister for my child. Only a Big Brother or Big Sister that I have approved will be matched with my child.
• Pertinent information from my child's file will be shared with the potential volunteer. This information will be shared on a first name basis only until a match has been agreed upon.
• Every reasonable precaution will be taken to ensure the safety of my child while he or she is participating in the BBBSCNNJ program. I relinquish all claims for injuries of any nature while my child is engaged in a BBBSCNNJ activity.