Heart of Iowa BBBS
Heart of Iowa BBBS Youth Application - School Based
Non-Discrimination Policy
Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability. 
Hidden Fields
To look up the owner's email for notifications
For notifications
Youth Information
Enter a date in the following format: mm/dd/yyyy
This is the year the youth will graduate.
Press CTRL while choosing to select multiple
Guardian Information
Type NA if unemployed
Family Information
NOTE for BBBS staff (delete before making the form live): You will need to update the drop down above with the corresponding options for your chapter. Once you've added the locations available to your chapter, go into the Update Contact steps in the submit connector and update the Agency Location mappings, using record IDs of the Agency Locations IDs as the send-as values 
Physical Address
Existing Household Members
Please choose this child's relationship to the following people:


Emergency Contact

Parent/Guardian Agreement

By signing below, I give permission:
  1. For my child to participate in the Big Brothers Big Sisters Program
  2. For the Volunteer matched with my child, who has been screened and approved by Big Brothers Big Sisters, to transport my child to events and match activities
  3. For the school to provide social and academic information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports)
  4. To have my child participate in an in-take interview conducted by Big Brothers Big Sisters staff and complete questionnaires throughout his/her time in the program containing questions about school, home life, and personal interests
  5. To have my child talk with a Big Brothers Big Sisters staff person about personal safety
  6. For BBBS staff to provide contact information for me and my child to the volunteer.

I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I will be asked to provide additional information through an in-person interview. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (i.e. demographic information, information relevant to volunteer preferences, and information relevant to child-safety and well being).

I certify that all of the information on this form is true and correct and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my qualification of the program.

I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly, or to me as his/her guardian. I understand that this information may be shared with the school or with partnership agencies when applicable.

If my child is matched with a Big Brother or Big Sister I agree to support my child's match by reviewing the program and safety information given to me by Big Brothers Big Sisters, communicating with Big Brothers Big Sisters staff as outlined in expectations. (which includes communication at least once a month in the first year of the match), and immediately reporting any concerns I might have to Big Brothers Big Sisters staff. 

Promotional/Social Media Consent

I (parent/guardian) hereby give my permission for Heart of Iowa Big Brothers Big Sisters to use the information: first name, last name, interests, pictures, etc.. That information shall be used by the organization identified above solely for the following purpose(s): Agency promotional materials, social media posts, newsletters, newspaper articles and other forms of promotional materials. 


I understand that no personal history information regarding granted by the consent form applies solely to the identifying information herein. In giving this consent, I release Heart of Iowa Big Brothers Big Sisters, its nominees and designees from any obligation of liability otherwise owed to me in connection with any personal or proprietary right I may have as a result of sale, reproduction or use of the above-referenced identifying information. I may terminate this terminate this consent at any time. 

Youth Safety Guidelines and Grounds Rules for School-Based Matches


  1. Mentor agrees to commit to at least one academic year.
  2. The Big and Little will consistently meet once a week. Please do not miss more than 3 times a year. 
  3. Mentor will consistently arrive on time each week.
  4. Big will adhere to the specific school procedure for match visits and will respect school rules and processes, including contacting school if unable to attend a visit. 
  5. All contact between Big and Little is restricted to school grounds and any BBBS sponsored activities. No additional contact should be initiated or unintentional by either party, and occurs naturally within the community, is permitted.
  6. Casual contact that is uninitiated or unintentional by either party, and occurs naturally within the community, is permitted. 
  7. Big is not allowed to transport the Little to any BBBS activity. Exceptions to this rule must be established well in advance with BBBBS in accordance with BBBS rules and policies. 
  8. The relationship between Big and Little is intended to be one-on-one with no other additional parties involved during the meeting time. Exceptions to this rule should be considered only after discussing with Mentor Coordinator. 
  9. Big and Little must maintain monthly contact with Mentor Coordinator throughout the school year and duration of the match. This may occur face to face, by phone or email. Failure to provide and maintain consistent feedback to Mentor Coordinator may result in the termination of the match
  10. If a problem arises in the match relationship, or if the Big or Little's personal information changes, Mentor Coordinator must be notified.
  11. Big and Little agree to complete any necessary paper work or BBBS surveys to meet the requirements and needs of the match and overall BBBS program.
  12. Big will not use alcohol or other illegal substances in the presence of the Little, nor will the Big engage in any activity that is in violation of the law while in the company of Little. 
  13. Big will follow district and school policies on dress code.
  14. Bigs will use discretion when discussing sensitive topics such as drugs, partying, sex...use common sense.
  15. Bigs and Littles will refrain from texting, receiving calls and/or spending time on social media while meeting with Little.
  16. Big will notify school and BBBS Mentor Coordinator if unable to make a meeting with Little.
  17. All personal information relating to Big and Little and Little's family should be kept confidential and only shared with Mentor Coordinator or other BBBS staff.
  18. If posting a photo of your Little, get parent permission first.
  19. Big and Little should make every attempt to meet in an open area/room such as library, hallway, classroom, gym...that is visible to other school personnel. If you do meet in a meeting room, the door must remain open. 
  20. The students restroom is for Littles only. Bigs must use an adult restroom.
  21. Bigs will follow school policy on food/drinks at school.
  22. THERE ARE NO SECRETS ALLOWED AT BBBS. This is a way to protect the Big and Little. If your Little shares a secret with you, please be aware that you are responsible for telling Mentor Coordinator immediately if it regards child safety. 
  23. Excessive gift giving is discouraged as relationships are built on trust and consistency. Gifts are allowed for special occasions, such as a birthday.

Contact Information