Mentee Application
Power Play is a free 8-week sport-mentoring program that aims to increase the availability of accessible and
inclusive sport and recreation opportunities in Ajax, Pickering, Oshawa, and Whitby. Children and youth between the ages
of 6 to 16 will engage in 1 of 4 unique sport programs that are led by certified coaches and Big Brothers Big Sisters
mentors. Participants will develop fundamental movement and sport skills, learn about good decision making, and develop
healthy relationships that will empower them to engage in sport and active living throughout their life.
To enroll your child in Power Play, please complete the form below. Completing this form does not guarantee
entry into the program. Registration for Power Play is on a first-come, first-served basis. Upon registration you will receive
an email to confirm enrollment. If the program is full you will have the option to place your child on the waitlist.
Please submit the completed form to Li-Ann at liann.yap@bigbrothersbigsisters.ca or drop the form off at
the BBBS Ajax-Pickering office. The information provided in this package will be kept confidential and used to
support program development so that we can provide participants with a best fit program.
Getting to know your child
Sex
Child’s Name
Date of Birth (mm/dd/yyyy)
School
Grade
Parent/Guardian Name
City/Town
M
F
Why does your child want to take part in Power Play?
Does your child currently participate in any organized sport programs? Have they participated in any organized sport
programs in the past? If so, please list them.
How did you hear about Power Play?
Big Brothers Big Sisters of Ajax-Pickering
1735 Bayly Street Unit 7C | Pickering, ON L1W 3G7
p. 905-831-3777
January 2015 Page 1 | 2
Please identify the TWO (2) sports your child is most interested in participating in. Your child will be placed in ONE
program. As stated above, the completion of this form does not guarantee entry into the program.

Sport
Gender
Age
Capacity
Location
Sherwood PS
Day
Dates
Time
TU
Mar 3 – Apr 28
No programs Mar 17
6:15pm – 7:45pm
Pickering Soccer Fields TH
Mar 5 – April 30
No programs Mar 19
5:30pm – 7:00pm
Volleyball
Co-ed
10 to 12
13 to 16
30
Soccer
Co-ed
6 to 9
10 to 12
30
Basketball
Female-only
10 to 12
13 to 16
30
Abilities Centre
WE
Mar 25 – May 13
4:30pm – 6:00pm
Floorball
Co-ed
10 to 12
13 to 16
20
TBC –
Cadarackque PS
SA
Apr 11 – Jun 6
No programs May 16
10:15am – 11:45am
Dress code: In order to safely participant in the program, all participants must wear gym attire. This includes running
shoes, track pants/shorts, a t-shirt and/or sweatshirt. Does your child need support to obtain these items?
Y
N
Transportation: Does the participant have transportation to and from the program?
Y
N
Y
N
If no, do you give permission for the participant (10+) to walk to/from Power Play on their own? I understand that
Power Play mentors and coaches are not responsible for such participants upon dismissal.
If yes, please list the name(s) and relationship(s) of the individual who will be providing the participant with
transportation
Absences: If your child cannot attend a Power Play session, the Power Play Project Coordinator must be contacted at 905-831-3777
a minimum of 10 hours prior to the day of the program absence. Two (2) unreported absences may result in your child being removed
from the program.
Parent/Guardian Signature
Date
Phone
Email
Release of Liability, Waiver of Claims, Assumption of Risks and Indemnity Agreement. Please Read Carefully!
I recognize that risk of injury or potential health risk may be involved in participation in the above-named program/activity. I hereby willingly assume such risk of injury or health
risk for myself or for the above-named person(s) for whom I am in law responsible and assume full responsibility before, during and after my/their participation in the
program/activity and any associated or related activities.
In consideration of the acceptance of my application and the permission to participate in the program/activity, I, for myself, my heirs, executors, administrators, successors and
assigns HEREBY RELEASE, WAIVE, AND FOREVER DISCHARGE Big Brothers Big Sisters of Ajax-Pickering and Big Brothers Big Sisters of Oshawa-Whitby, all other
organizations, associations and companies associated with any of the programs offered by Big Brothers Big Sisters of Ajax Pickering and Big Brothers Big Sisters of OshawaWhitby, and all their respective agents, employees, officials, servants, contractors, representatives, elected and appointed officials, successors and assigns OF AND FROM
ALL claims, demands, damages costs and actions whatsoever and however caused, arising or to arise by reason of my participation in the program or any of its associated
activities.
January 2015 Page 2 | 2