My child's school /
  after school program

Information BBBS should
know about my child
(allergies, medications, etc.)

By submitting this application, I indicate my agreement that ...

I give my child (named above) permission to participate in the Big Brothers Big Sisters Program.

I understand that it may be necessary for Big Brothers Big Sisters of Greater Nashua to obtain feedback from my child's school and other agencies through references. I hereby give my consent for this information exchange and authorize such agencies to release the information requested by Big Brothers Big Sisters of Greater Nashua.

I release Big Brothers Big Sisters of Greater Nashua, its directors, staff and agents from responsibility for accident, injury or illness that may befall my child while participating in the program.

I authorize that medical personnel in the event of an emergency may treat my child while participating in the program.

I understand that the agency has eligibility criteria that will be taken into consideration and that parental permission does not mean automatic acceptance into the program.

I give my permission for my child's first name and picture to be used by the program in publicity releases (ex. Newsletter) and presentations by program staff and directors.