Our Virtual Buddy Program offers fully vetted volunteers, who are excited to meet with Hamilton Extend-A-Family kids and youth online under the supervision of caregivers!

CRITERIA:

The criteria for participation in this program require that EAF participants have some computer skills, the family has the ability to engage in ZOOM meetings, and that the child benefits and enjoys online interactive socialization.

OUR VOLUNTEERS:

Our volunteers have provided current vulnerable sector checks and we have checked their references. Our volunteers are provided training and are scaffolded with ongoing support by EAF Staff. We attempt to match the volunteer’s interests with the child to try to create an ideal match, that will develop long lasting social connections. Our volunteers are committed to provide a minimum of one hour of online support per week by meeting with their matched child or teen to share fun activities.

WHAT WILL THEY DO?

Virtual Buddies do all sorts of different activities together online, sometimes they just talk, sometimes they read, sometimes they dance, or play games. It all depends on the child and their interests. Our volunteers are provided with a variety of resources to interest and engage their Virtual Buddies. They also have access to crafting kits and art supplies that can be shared with a child to encourage creative time.

NEXT STEPS:

If this program sounds like a good fit for your child, please complete and review the application form below.

Apply To: HAmilton Extend-A-FAmily “Virtual ONly” Program

Name *

First Name

Last Name

DATE OF BIRTH *

YYYY

Gender Identity

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Resides With

Mother

Father

Guardian

Other please explain:

Other:

Email *

Diagnosis *

Autism

ADD

ODD

Downs Syndrome

ADHD

Tourette's Syndrome

FASD

OCD

PDD

OTHER (Please identify)

Please list any additional diagnosis:

Does your child have any medical issues that may need to be monitored during a virtual visit? (example: seizures, mobility, or dietary restrictions)

Please share restrictions or guidelines for your child’s online activities that your support person needs to be aware of:

Please share your child’s interests and favourite activities to assist us with providing support that is unique to them: *

Child's Technological Proficiency *

On a scale of one to ten, with ten being the highest level, what level of technological comprehension best describes your child’s abilities: (How capable are they when using a computer?)

Primary Contact *

First Name

Last Name

Relationship to the Child:

Primary Contact Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact Home Phone Number: *

(###)

###

####

Primary Contact Mobile Phone Number:

(###)

###

####

Primary Contact Email: *

Secondary Contact

First Name

Last Name

Relationship to the Child:

Secondary Contact Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Contact Home Phone Number

(###)

###

####

Secondary Contact Mobile Phone Number

(###)

###

####

Secondary Contact Email:

HOUSE HOLD INFORMATION: Who else lives in the child's home? Name: What is there relationship to the child? What is there age?

Please list the following for all: Name; Relationship to the Child; Age.

WAIVER: The Staff and Volunteers of Extend-A-Family are required to sign a confidentiality agreement prior to working with families and will ensure that your privacy is maintained, with the following exceptions: • They are required by law to report any incident of perceived child abuse • They are required by law to report any indication that a person intends to harm themselves or others • Staff and volunteers will respectfully discuss familial information that is relevant to providing the best client centered support possible Information regarding your child will only be shared with Contact Hamilton or other agencies having a relevant interest in their well-being, with the utmost discretion. Such correspondence will be documented and copied to the child’s parent or guardian.

As the parent or guardian of the above-named client, do you give consent to Hamilton & District Extend-A-Family to share information about this individual with professionals from other agencies? *

Yes

I grant Hamilton & District Extend-A-Family staff and adult volunteers the authority to obtain emergency medical treatment as necessary to ensure that the above-named client is protected from further harm or injury. I agree to waive and release Hamilton & District Extend-A-Family from all claims for damages that may arise, other than by negligence of Hamilton & District Extend-A-Family, or its employees, volunteers, and agents, as a result of this child’s participation in agency events: *

Yes

I grant Hamilton & District Extend-A-Family consent to use photographs or video footage taken by agency staff or volunteers to promote our agency via internet, social networking sites, agency newsletters, brochures, and other media: *

Yes

Name of Parent/Guardian *

First Name

Last Name

Date of Application *

YYYY

Electronic Signature *

By placing my name I acknowledge that I am electronically signing this document.

Notes:

Thank you, for your application to the Virtual Buddy Program. We should be in touch with you soon!

In-House Programs Pre-Screening Form

All participants must complete a pre-screening survey online each time prior to attending our programs. Participants will not be permitted to join in-person events until a parent/guardian has successfully completed the survey.

Name of Participant *

First Name

Last Name

Age of Participant *

Name of Parent or Guardian *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best telephone number to reach you in the event of an emergency *

Permission to collect information electronically *

Yes

Have your child or anyone in your household felt hot or feverish in the last 10 days? *

Yes

Do you or anyone in your household have any of these symptoms: New or worsening cough? New or worsening shortness of Breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose? *

Yes

Has your child had any symptoms of MIS-C including: Fever that lasted 24 hours or longer? Vomiting? Diarrhea? Pain in the stomach? Skin rash? Red eyes? Redness or swelling of the lips and tongue? Feeling unusually tired? Redness and/or swelling of the hands or feet? Headache that’s unusual or long lasting? *

Yes

Have you experienced a recent loss of smell or taste? *

Yes

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

Yes

Have you returned from travel outside of Ontario in the last 14 days? *

Yes

If you answered "yes" to travelling outside of Ontario - where did you travel to?

Is your workplace or the workplace of anyone in your household considered high risk? *

Yes

I give permission for my child/teen named as above to attend Hamilton & District Extend-A-Family events recognizing that there is potential risk in in-person events despite the precautions taken. *

Yes

Signature of Parent or Guardian *

Date of Signature *

YYYY

Thank you for Completing the Programs Pre-Screening Survey!

Please note: Participants will be asked to have their temperature checked using a contactless thermometer prior to entry.

Donate Now

Hamilton & District Extend-A-Family, 2-1022 Barton Street East, Hamilton, ON, L8L 3E4, Canada905-383-2885eaf@execulink.com

Send Mail to: 2-1022 Barton Street East, P.O. Box 47578, RPO Centre Mall, Hamilton ON L8H 7S7

ALL ARE WELCOME!

Hamilton & District Extend-A-Family welcomes individuals of all genders, sexualities, and racial backgrounds.

Registered Charitable Number 11895 1557 RR0001

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