Game On Registration Form - In School

  • Thank you for your interest in the Game On! program. Once your submission has been reviewed by our team, you will receive an email confirmation with more details about the program.

  • MM slash DD slash YYYY
  • This response is voluntary and will be used for statistical purposes only.
  • This response is voluntary and will be used for statistical purposes only.
  • We realize that this information can be of a sensitive nature and it will be treated with confidence and respect.
  • We ask because some of the group discussion will be on healthy balanced eating and we want to make sure we are sensitive to each participant’s dietary needs when holding these discussions.
  • Ex. religious or cultural views, stressors, other existing issues?
  • All sessions will take place virtually over Zoom video conferencing. In order to participate, your child will need private access to the Zoom app for each session.
  • Online Program Consent

    As the parent/guardian, I understand the following rules, which will be reinforced during the first session and periodically throughout the program: 1. Participants and Mentors are not permitted to share information about one another outside of the group 2. The chat function will be set so that all comments will be visible to the Mentors and no private chats between participants will be possible 3. Participant and Mentor contact will be limited to the pre-scheduled sessions 4. Any communication that occurs outside of scheduled meetings cannot be supervised by Mentors or BBBSY staff and are therefore under my discretion and supervision as the parent/guardian. As the parent/guardian, I agree to: 1. Support and encourage my child to participate in each session 2. Provide support or feedback to the Mentors if required 3. Check in with my child following each session to determine how they are responding to the program 4. Contact BBBSY immediately should any concern arise from my child’s participation in this program
  • You are encouraged to review Zoom’s privacy policy which can be found here: Each program is supported and monitored by a BBBSY Program Staff member.
  • Media Consent

  • Please select your response to the Media Consent statement listed above.
  • Informed Consent

  • I have read and understand this agreement. By checking YES, I acknowledge that I am the parent/guardian of the child for whom I am applying and that 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 BBBSY. 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.
  • Parent/Guardian Signature