I choose to apply to be a volunteer for Big Brothers Big
Sisters of Palm Beach and Martin Counties.
For this reason, I give the following permission to the agency:
I do hereby authorize representatives of Big Brothers Big Sisters
of Palm Beach and Martin Counties to seek and obtain any information
regarding myself deemed necessary by them, to provide quality, safe services to
children in their programs. This
authorization includes requesting or releasing confidential information from/to
the following individuals or agencies:
schools, social services, organizations, therapists, physicians,
I understand that this will be considered confidential; and
will not be released to other individuals or organizations without my specific
consent. I am aware that this consent
will expire when my volunteer work is formally terminated with the agency. I am also aware that this consent may be revoked
by me at any time. My signature indicates that I know what information will be
disclosed and the purpose for which it will be used. My signature also means I have read this form
or had it read to me and explained in language I can understand.
I agree and consent to the use of profile information in
such form and manner as deemed appropriate by Big Brothers Big Sisters of Palm
Beach and Martin Counties for recruitment and development purposes.
I hereby release, remise and forever discharge Big Brothers
Big Sisters of Palm Beach and Martin Counties, its officers, and employees,
successors and assigns from any and all rights of action, liability, demands or
claims accruing or to accrue out of this use or resulting from any rights of
action, liability, demands or claims relating to libel, slander or invasion of
the right of privacy.
The references and youth organizations that I have worked
for or been involved with as a volunteer whose information I have provided may
be contacted by telephone or email.
I am in no way obligated to perform any volunteer services.
I hereby authorize Big Brothers Big Sisters of Palm Beach
and Martin Counties to secure information it deems necessary from the
following sources: medical records, employers, educational institutions, the
military, criminal records, National and State Sexual Offenders and Predators
Check, and any other pertinent sources to evaluate my potential as a volunteer.
Continued involvement will be based on the information discovered.
Big Brothers Big Sisters of Palm Beach and Martin Counties has
the right to accept or deny program participants and is not obligated to match
me with a youth. Big Brothers Big Sisters is not required to provide me with a
reason if I am not accepted or matched with a youth.