Pumped for Post-Secondary

High School Student Application Form

Pumped for Post-Secondary (PFPS) High School Student Registration Form

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1Page 1 of 4 General Information

2Page 2 of 4 Primary Caregiver & Emergency Information

3Page 3 of 4 Program Choice

4Page 4 of 4 Consents

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Get a better understanding of what life after high school can look like. Pumped for Post-Secondary is an on campus, group-based mentoring program for high school youth in grades 9-12. With guidance from current post-secondary mentors and guest presenters, youth will take part in campus tours, mock lectures, resume building workshops, financial literacy activities, and so much more! Over 10 to 13 sessions, youth will build confidence, develop new skills, and learn how to navigate life after high school. Snacks and bus tickets for youth will be provided.

The information you provide on this form will be maintained as a confidential, secure record.

Do not close this browser window before submitting the form, as your progress may be lost. For longer responses, consider saving your work in a Word or text document as you go, just to be safe.

General Information

Youth's Name*

First Last

Youth's Address*

Street Address

City*

Postal Code*

Home Phone*

Birthdate*

Age*

Grade*

Please enter a number from 9 to 12.

High School*

Born in Canada?*

Yes

If no, where was the youth born?*

Language(s) spoke at home

(for statistical purposes only)

Cultural/Racial Identity

(for statistical purposes only)

Does the youth identify as an Indigenous person?

Yes

(for statistical purposes only)

Food Allergies, Restrictions, Medical Concerns:*

(Snacks will be served in the program)

Family Information

(For statistical purposes only, names will not be used)

Is your family experiencing financial barriers?*

Yes

Choose not to disclose

Additional details:

Do not close this browser window before submitting the form, as your progress may be lost. For longer responses, consider saving your work in a Word or text document as you go, just to be safe.

Program Choice

* Langara program: Thursdays, 4:30pm to 6:00pm from October to March

* KPU (Surrey) program: Thursdays, 4:15pm to 5:45pm from October to March

Program dates vary by site; please click here to view site schedules and program dates

Choose ONE site only:*

Langara College

Kwantlen Polytechnic University (KPU) Surrey

Review and confirm your understanding of the Langara College requirements:*

I understand that the youth will be required to attend a training session on campus at Langara College. The date and time will be confirmed closer to the program start.

Review and confirm your understanding of the Kwantlen Polytechnic University (KPU) Surrey requirements:*

I understand that the youth will be required to attend a training session on campus at KPU Surrey. The date and time will be confirmed closer to the program start.

Program Dropoff

(Both programs take place on Thursdays, starting at 4:30pm at Langara and 4:15pm at KPU Surrey)

Check all that apply:*

My youth has permission to walk/bus to Langara College/KPU Surrey for the program

My youth will be dropped off by a parent/guardian at Langara College/KPU Surrey for the program

Program Pickup

(Both programs take place on Thursdays. The program ends at 6:00pm at Langara and 5:45pm at KPU Surrey)

Check all that apply:*

My youth has permission to walk/bus home from Langara College/KPU Surrey after the program

My youth will be picked up from a parent/guardian from Langara College/KPU Surrey after the program

Please list the full names and phone numbers of people who are allowed to pick up your youth and their relationship:*

(click + to add more people)

Full Name

Phone Number

Relationship to youth

Accommodations & any other conditions/traits that may impact how the youth participates in the program:*

Do not close this browser window before submitting the form, as your progress may be lost. For longer responses, consider saving your work in a Word or text document as you go, just to be safe.

Informed Consent (Site Based group program) – Parent/Guardian

Please review the following and click the checkbox to confirm your consent:

I hereby give permission to Big Sisters of BC Lower Mainland to make available their service to my youth. It is my understanding that the intention of the Agency is to offer my youth an opportunity to participate in a group program led by a responsible adult, (minimum 18 years old), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program.
In consideration for this service and other valuable consideration provided to my youth by Big Sisters of BC Lower Mainland, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my youth. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof.
I understand that the collection of personal information about me or my youth will be held in strict confidence and is to be used solely for the purposes of administering the program. I further agree that information about my youth may be shared, at the discretion of Big Sisters of BC Lower Mainland, with the group facilitator so that my youth’s needs may be best met.
I understand that this application is the property of Big Sisters of BC Lower Mainland. I also agree that my youth will participate in the Pre-Match Training Program administered by Big Sisters of BC Lower Mainland.

Consent*

I consent to the above terms.

Photographs & Audio/Video Recordings Consent

Photographs – For use in program only*

I give consent for photos of my youth to be taken for the sole purpose of giving each participant a printed photo(s) of themself and/or of the group at the end of the program.

I do not give consent for photos of my youth to be taken for the sole purpose of giving each participant a printed photo(s) of themself and/or of the group at the end of the program.

Photographs & Audio/Video Recordings - For public/external use*

Photos and/or audio/video recordings of our Group Programs are occasionally used to help us publicize and promote the programs and services of Big Sisters of BC Lower Mainland. This may include use of photos, audio/video recordings, and first names of participants in newspapers/ magazines, on radio/television, on the Big Sisters website or newsletter, and in other promotional materials.

In the section below, please indicate whether you give us consent to use photos/recordings of your youth and their first name for publication.

I give consent for photos and audio/video recordings of my youth to be taken and used to publicize the work of Big Sisters.

I do not give consent for photos and audio/video recordings of my youth to be taken and used to publicize the work of Big Sisters.

Use of Youth's First Name Consent

(Big Sisters does not release last names of participants)

Can we use your youth's first name to publicize the work of Big Sisters?*

I give consent for my youth’s first name to be used to publicize the work of Big Sisters

I do not give consent for my youth’s first name to be used to publicize the work of Big Sisters

I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE:

I request Big Brothers Big Sisters service for my youth. I give my youth permission to participate in one or more group programs offered by Big Sisters of BC Lower Mainland. I am aware of and understand the risks, dangers and hazards associated with the above service and agree that such service is suitable for my youth.

Parent/Guardian Name*

Parent/Guardian Signature*

Date signed *

November 5, 2026

Date signed*

Pumped for Post-Secondary

High School Student Application Form