Volunteer Enrollment Form

Transcription

1 Volunteer Enrollment Form Page 1 of 5 Please note: Big Brothers Big Sisters of the 7 Rivers Region does not discriminate on the basis of gender, race, color, physical condition, marital status, religion, sexual orientation, veteran status, national origin or disability. Indicate your program preference: Site-based Mentoring Community-based Mentoring No Preference / Unsure Legal Name - First: Last: Maiden/Alias: Middle: Date of Birth: Gender: Male Female Transgender Veteran? Yes No Single Married Divorced Separated Widowed Living with significant other Domestic partner Ethnicity (Choose all that apply): American Indian or Alaska Native Asian African American Hispanic Native Hawaiian or Pacific Islander Caucasian Some other race Disabilities: Special Accommodations: A person has a disability if he or she has a physical or mental impairment which substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. Permanent Address: County: City: State: ZIP: Student Only Local Address: County: City: State: ZIP: Home Work Phone (w/ ext.): Cell Preferred Home Work Cell Best time to call: Morning Afternoon Evening Primary Secondary Level of Education: No High School Some High School High School Graduate Some College Associate Degree Bachelor s Degree Master s Degree PhD Juris Doctorate School: Years Completed: Graduation Date: Employer: Work Address: City: State: ZIP: Occupation: Work Hours: How long employed? If requested by your employer, can we share that you are a volunteer in our program? Yes No Emergency Contact: Relationship: Valid driver s license? Yes No State Issued: Possession of a driver s license is not a requirement for participation in our programs but is required if you will be transporting youth in any vehicle you are operating. Proof of auto insurance is also required for transporting youth.

2 Volunteer Pre-interview Questionnaire Page 2 of 5 The information you give below will help us make a better match for you and assure we can support you during involvement with our program. If requested, we will share pertinent information with the caregiver of the youth with whom you may be matched. All identifying information will remain confidential until your match is finalized. 1. Which do you enjoy?: Watching events or activities Actively participating in activities Both 2. Are you experiencing any physical or mental health problems? Yes No If Yes, please provide a description. 3. Have you ever been arrested, charged, or convicted of a crime? Yes No If Yes, you must provide a description. If you fail to disclose any arrest(s), charge(s) or conviction(s), this will directly impact the agency s decision to advance your enrollment application. 4. How long have you lived in the area? 5. Do you anticipate any significant life changes over the next year or have you had any in the past year? Yes No If Yes, please provide a description. 6. Do you speak any foreign languages? Yes No If Yes, please specify language(s): 7. In identifying a youth for you to work with, are there any special considerations you want us to know about? Yes No If Yes, please provide a description: 8. Please describe your personality, interests, hobbies and anything else you'd like to tell us about yourself. Do you have any questions for Big Brothers Big Sisters?

3 Page 3 of 5 Community-Based Only 1. Which do you enjoy more?: Indoor Activities Outdoor Activities No Preference 2. Do you have any guns or ammunition in your house? Yes No If Yes, describe the safety precautions in place to protect children (e.g., gun safe). Safety precautions are required prior to match. 3. Can you secure or make unavailable printed materials, videos, Web sites, television programs and other materials that are inappropriate for youth? Yes No Does Not Apply (If No, we will discuss during the in-person interview.) 4. Do you have any pets? Yes No If Yes, indicate the type of pet(s) and describe any history of aggression (biting, etc). 5. Have you had any driving citations and/or moving violations in the past 5 years? Yes No If Yes, you must provide a description. Site-Based Only What day(s) and time(s) are you available to volunteer? 7-8 a.m. 8-9 a.m a.m a.m. 11 a.m.-12 p.m p.m. 1-2 p.m. 2-3 p.m. 3-4 p.m. 4-5 p.m. 5-6 p.m. 6-7 p.m. Monday Tuesday Wednesday Thursday Friday 6. Do you have transportation to a mentoring site? Yes No If Yes, please describe your mode of transportation (e.g., I own a vehicle, etc).

4 Youth Experience References Page 4 of 5 Have you ever applied to be a Big Brother or Big Sister? Yes No If yes, where and when? Have you previously been a Big Brother or Big Sister? Yes No If yes, where and when? Have you previously volunteered or worked with youth? Yes No If yes to any of the above, you must provide the following information. If no, proceed to Personal Reference Form. Youth Experience Reference #1 (most recent) Name of Organization (if applicable): Role/Position: Dates Involved: Youth Experience Reference #2 (if applicable) Name of Organization (if applicable): Role/Position: Dates Involved: Personal References (required) List three references who can attest to your reliability, sense of responsibility and work/service ethic. Reference #1: Current or past employer, who has known you for at least one year Reference #2: Spouse, Partner, or Significant Other (or Parent if none). Reference #3: Person, other than a family member, who has known you for at least three years, has seen your home environment and has observed your interactions with children.

5 Page 5 of 5 Please list any states in which you have lived in the past seven (7) years. Please include address, county and your dates of residence there: With completion of these enrollment forms and my signature below, I acknowledge that: 1. The references I listed may be contacted by mail, telephone or I am in no way obligated to perform any volunteer services. 3. Big Brothers Big Sisters of the 7 Rivers Region is not obligated to match me with a youth. 4. The information I provided may be used to conduct a background check, including driving records check, criminal background check and other records where required by local, state or federal law for volunteers working with youth. 5. Other Big Brothers Big Sisters agencies or youth organizations where I have worked or volunteered may be contacted as references. 6. As part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations for program acceptance. 7. In the event of the agency s determination of my ineligibility, reasons for non-acceptance will not be disclosed, in accordance with agency policy. Print Name: Signature: Date: