New Mentee Parent Forms
New Mentee Forms
1
Parent Referral Form
2
Parent Permission Slip
Parent Referral Form
Child's Name
*
First
Last
Child's Date of Birth
*
Month
Day
Year
Child's Gender
Parent/Guardian Name
*
First
Last
Relationship to Child
*
Please list the individuals that live with the child and the relationship with the child:
*
Are there any activities that your child is involved in that make meeting with a mentor difficult? (Band, Football, Basketball, Cheerleading, etc.)
*
Please describe your child's interests and hobbies:
*
Does your child have any behavioral, emotional, medical concerns, or special considerations?
*
Other Comments:
Parent/Guardian Signature: Please type your full name below
*
Today's Date
*
Month
Day
Year
Parent Permission Slip
Child's Name
*
First
Last
Child's Preferred Name
Child's Date of Birth
*
MM slash DD slash YYYY
Child's Ethnicity
School
*
Old Town Elementary School
Leonard Middle School
Lewis Libby 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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Mailing Address (if different than home address)
Street Address
Address Line 2
City
State
ZIP Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
*
MM slash DD slash YYYY
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New Mentee Parent Forms