New Mentee Parent Forms

Parent Permission Slip

Child's Name*

First Last

Child's Preferred Name

Child's Date of Birth*

Child's Ethnicity

School*

Grade*

Teacher*

Name of Parent/Guardian*

First Last

Relation to Child*

Do you have legal custody of child?*

Yes
No

Home Address*

Street Address Address Line 2 City State ZIP Code Country

Mailing Address (if different than home address)

Street Address Address Line 2 City State ZIP Code Country

Parent/Guardian Email*

Would you like to receive program email announcements/alerts?*

Yes
No

Phone*

Type of Phone*

Home
Mobile

What is the child's living situation?*

2-parent
1-parent
Other Relative

Please check if you or your child receives the following:

TANF
SNAP
MaineCare
Free/Reduced Lunch
Subsidized Housing

Please check if either applies to your child:

Child of current/formerly incarcerated parent
Child of military parent

Has the applicant had any prior involvement with the Juvenile Justice System?

Yes
No

If yes to the previous question, please describe involvement:

Does your child have any allergies?

Is your child taking any medications?

Preferred Site(s)*

Old Town Elementary School
Leonard Middle School (Old Town)
Lewis Libby School (Milford)
Old Town-Orono YMCA*

*Child must be enrolled in the Afterschool Program

My child may walk from the chosen site.*

Yes
No

Please list anyone who IS ALLOWED to pick up your child (ID will be required).*

Please list anyone who is NOT ALLOWED to pick up your child.

Mentor/Big Preferences:

Though the Black Bear Mentor Program does not discriminate against volunteer applicants or children, parent/guardians do have the right to express preferences about the volunteer that their child is matched with. We will make every effort to comply with these preferences, but we cannot guarantee the characteristics of the mentors. Please indicate your preferences, if any, below:

Woman
Man
No Preference

Preferred Religion

Preferred Ethnicity

Other Preferences or Considerations

"TheApp" Parental Consent*

Big Brothers Big Sisters of Mid-Maine (BBBSMM) offers an online communication tool, "TheApp" to help matches stay connected when they are not able to meet in-person. "TheApp" is part of Big Brothers Big Sisters' online data organization system; and all communication between Bigs and Littles is monitored by Agency Staff.

I give permission for my child to communicate with their Big using "TheApp"
I DO NOT give permission for my child to communicate with their Big using "TheApp"

Please read the following carefully and click on each statement to indicate your agreement.*

I give permission for my child, (named above), to participate in the Black Bear Mentors/BBBSMM program one day per week. In doing so I understand and agree to the following:

My child (Little) will meet with a University of Maine student (mentor/big) at least one hour per week, November through May.
I authorize my child’s school (listed above) and any subsequent schools that she/he attends to release grades, attendance, and social reports about my child to the Black Bear Mentor Program and Big Brothers Big Sisters of Mid-Maine Program Staff to be used for reporting purposes.
All applicant information in regards to my child, including home address, will be kept strictly confidential
I authorize Black Bear Mentor Program Staff along with Big Brothers Big Sisters of Mid-Maine to have my child complete a questionnaire about school, home, and personal interests.
I authorize the Black Bear Mentor Program Staff along with Big Brothers Big Sisters of Mid-Maine Staff to talk with my child about personal safety
Black Bear Mentors/BBBSMM does not guarantee my child will be matched and has discretion in creating and/or closing a match in regards to child safety and the best interests of all parties involved.
I understand that contact with my child’s mentor outside of the mentoring activities is not permitted.
I authorize the Black Bear Mentor Program Staff along with Big Brothers Big Sisters of Mid-Maine to use my child’s photo and first name only in any materials in print, on websites, or on social media to highlight match successes and recruit Bigs and Littles. (Please do not check this box if you do not wish to authorize)

Special Event Permission*

I give permission for my child to be transported from their school to the University of Maine, and back for the Spring Campus Visit, which we will predict will be in April.
I do not give permission

There are typically two events during the year that happen at the University of Maine. Your child will be picked up at their school, brought to UMaine, and then returned to the school. We generally choose two days during the week for the visits, and we will coordinate with you what day is best for your child to attend. (More information will be provided to you before the visits.)

Electronic Signature (please type your full name below)*

First Last

Today's Date*

Bodwell Center for Service and Volunteerism

New Mentee Forms

Parent Referral Form

Parent Permission Slip