BBBS Drop-In Mentoring Registration 2022-2023

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Mentoring Programs run Wednesdays at L&A Library - 25 River Rd. Napanee, K7R 3S6
Participants must only complete registration once.

Please complete form in full. Staff will reach out to confirm registration.

If you have any questions, please call Graham at 613-561-0576

Email *

Name of Child/Youth: *

My child/youth is: *

6-10 years old

11-16 years old

Child's Address: *

My child/youth attends:

JJ O'Neill CS

Southview PS

The Prince Charles School

Napanee District Secondary School

Other:

Clear selection

Parent/Guardian Name:

Relationship to Child/Youth:

Parent/Guardian Email Address:

Parent/Guardian Phone Number:

Please provide two emergency contact phone numbers : *

Does your child/youth have any allergies, medical or special needs? - If yes, please see staff for additional form to be completed. *

How will your child/youth be getting to/from the program? - If participant will be arriving independently, please see staff for additional permission form.

If transportation was available to your child/youth would this be beneficial to you/your family?

Yes

Maybe

Other:

Clear selection

Do you give consent to BBBS KFL&A to use any media (photos, videos) of your child for the purpose of promotion on social media, website, news articles, etc?

Yes

Clear selection

I am interested in learning about more mentoring programs available to my child.

Yes

Other:

Clear selection

I am the legal guardian of this participant, and I consent to them being a part of Big Brothers Big Sisters group programs.

YES

Clear selection

Parent/Guardian Name/Signature:

Send me a copy of my responses.

Submit

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