High School Bigs: Volunteer Enrollment Form

Mentor Program

Which mentoring program are you applying for?

Our "High School Bigs" program is one-to-one mentoring supervised and held on site at school

Program ID

Volunteer Information

First Name

Last Name

Date of Birth

Home Address

Line 1

Home Address

Line 2

City

State

Zip Code

Cell Phone

By providing a mobile number, you give Big Brothers Big Sisters permission to contact you using automated text messages for reminders, updates, and events.

Home Phone

Personal Email

Different than your school email

School Email

Race/Ethnicity

Gender

How do you identify?

Sexual Orientation:

Annual Household Income

Number of people supported by this income:

Involvement in the foster care system:

Currently in foster careFormerly in foster careNever in foster care

School

Other

Please type your school here if it's not listed above

School District

Graduation Year

This is the year the child will graduate from high school.

Current Grade Level

School ID #

Dismissal Time

Have you ever applied to be a Big Brother or Big Sister?

YesNo

If so, where?

How did you hear about Big Brothers Big Sisters?

Referral Detail ID - IE

Parent/Guardian Information

Mother's/Guardian First Name

Mother's/Guardian Last Name

Father's First Name

Father's Last Name

Mother's/Guardian Cell Phone

Father's Cell Phone

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Cell Phone

Emergency Contact Home Phone

Relationship to Volunteer

References

Reference #1: Parent

First Name

Last Name

Cell Phone

Email

Reference #2: Teacher, Coach or Other Adult Not Related to You

First Name

Please include a non-relative who knows you well

Last Name

Cell Phone

Email

Volunteer Health Information

Allergies Description

(ex. peanuts, bees, penicillin)

Other

Please explain any other health conditions

Are you taking any medications?

YesNo

Medications Description

(ex. EpiPen, Inhaler)

Volunteer Consent

Program Description: One-on-one mentoring supervised and held on site at school. This fall (2020), all sessions will be virtual.

1. I desire to participate in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) High School Bigs Program (the “Program”) as a volunteer mentor, or “Big.”

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2. I understand that all the information obtained through the enrollment process is the sole property of BBBSOC/IE and that I relinquish my rights to access this information.

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3. I authorize BBBSOC/IE to obtain medical and/or surgical treatment in case of illness, accident, or any situation that may arise. These medical services are to be performed by ______type name below______ or in his/her absence, any licensed medical doctor. I further state that I will not hold BBBSOC&IE liable in case of illness, accident or emergency situation.

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First Name

Last Name

4. I understand that if I am not accepted into the program, I will not be provided with an explanation.

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5. I understand that if I am accepted into the program, at least one full year commitment is required. If I do not uphold this commitment without a valid reason, I understand that I am not eligible to receive credit for service hours already completed.

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6. I understand that Big Brothers Big Sisters has the right to conduct a public domain search (including social media profiles) and can accept or deny service based on the search findings.

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7. I attest that all the information provided on this enrollment form is to the best of my knowledge true and accurate and that I fully understand all the questions and statements herein.

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8. I the undersigned, understand that all information I disclose to BBBS, whether disclosed in my Volunteer Enrollment Form, questionnaires, interviews or otherwise, and whether in writing or orally, may be disclosed to the parent or guardian of a prospective or matched Little Brother/Little Sister and I hereby consent to such disclosure.

Initials

I have read and understand the above statements.

I Agree

Parent Consent

I, the undersigned, give permission for my child to participate in the BBBSOC/IE High School Bigs Program as a volunteer mentor or Big. I have read and agree to the above consents/releases.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Participant Signature
Reset Signature

Printed Name of Participant

Date Signed

Media Consent and Agreement

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”). I hereby accept the invitation of Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) for My Child to appear and be identified in print or online in any BBBSOC/IE publication or production. I hereby grant BBBBSOC/IE and its affiliates the absolute right and permission to use the image, name, and biographical information of My Child as BBBBSOC/IE may desire, in all media and in all forms whatsoever, including, but not limited to: magazines, brochures, press releases, print publications; motion pictures, television, cablecast and satellite broadcasts; the internet and mobile applications. Examples include, but are not limited to, the Orange County Register and other print news media, televised news media, promotional print media, and the BBBSOC/IE website and social media channels. In consideration of $0 to be paid to me, I hereby grant to BBBSOC/IE and its affiliates the absolute right to use images made through BBBSOC/IE studios or elsewhere, in whole or in part, in true or distorted character or form, alone or in conjunction with any other image, name or reproduction, in color or otherwise, for art, advertising, promotion, business, trade, or any other lawful purpose whatsoever, in perpetuum.

I hereby waive any right that I may have to inspect and/or approve of the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied.

I hereby release BBBSOC/IE and its affiliates from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSOC/IE ’s exercise of the right hereby granted. These include, without limitation, claims for compensation, claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory. BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

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2. I do not grant Big Brothers Big Sisters of Orange County/Inland Empire the right to use the image of the minor child specified below.

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I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Minor Volunteer Signature
Reset Signature

Printed Name of Minor Volunteer

Date Signed

Relation to Minor Volunteer

Communication Consent & Agreement

Given the current school closures and ongoing uncertainty surrounding the COVID-19 pandemic, we understand that this can be a difficult time for your families to try and navigate. While the High School Bigs Program rules and guidelines typically do not allow Bigs and Littles to exchange contact information (such as phone numbers or email addresses), we are able to make specific exceptions and would live to provide our participants with options for ways to stay connected.

Please initial one of the two boxes below and sign and complete all information at bottom of form.

1. I am the parent/guardian of the minor child specified below (“My Child”), who is participating in the High School Bigs Program (the “Program”) offered by Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) as a volunteer mentor, or “Big”. I hereby consent and give My Child permission to communicate virtually and/or electronically with My Child’s Little or mentee. Such communication may include, without limitation, telephone, text message, email, and video conferencing programs such as Zoom, CommandLink, Google Classroom, and Facetime.

I WILL COMMUNICATE WITH MY CHILD, WITH MY CHILD’S LITTLE OR MENTEE, AND WITH BBBSOC/IE TO DETERMINE WHICH COMMUNICATION METHODS AND PLATFORMS I APPROVE.

I further agree to supervise, monitor, and otherwise stay informed about My Child’s virtual and/or electronic communication with My Child’s Little or mentee, and to maintain an open dialogue with My Child concerning these virtual and electronic interactions.

I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, volunteers, agents, affiliates, successors, and assigns, arising out of or attributable to My Child’s virtual and/or electronic communication with My Child’s Little or mentee.

BY INITIALING THIS OPTION AND SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS.

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2. I do not consent or give My Child permission to communicate virtually and/or electronically with My Child’s Little or mentee, or other Littles or mentees participating the program.

Initials

I have read and understand the above statements.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Minor Volunteer Signature
Reset Signature

Printed Name of Minor Volunteer

Date Signed

RELEASE AND WAIVER OF LIABILITY

I, the undersigned, am the parent and/or legal guardian of ___type name below___ , a minor (“My Child”), and I agree to permit him/her to attend and participate in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) High School Bigs Program (the “Program”) as a volunteer mentor, or “Big.”

I understand that certain risks and dangers may exist in My Child’s attendance and participation in the Program, and such attendance and participation is conditioned upon my agreement to release BBBSOC/IE from any claims of liability, including, but not limited to, any claims for property loss or personal injury to My Child. Therefore, in exchange for the opportunity of My Child to attend and participate in the Program, I hereby expressly waive and release any and all claims which I may have, or which I may hereafter have, whether known or unknown, against BBBSOC/IE, and its officers, directors, staff, employees, agents, affiliates, successors, and assigns (collectively, “Releasees”), on account of injury, death, property damage, or economic loss arising out of or attributable to My Child’s participation in the Program, including, without limitation, to travel to or from their school/site or field trip/program destinations, whether arising out of the ordinary negligence of BBBSOC/IE or any Releasees or otherwise. I covenant not to make or bring any such claim against BBBSOC/IE or any other Releasee, and forever release and discharge BBBSOC/IE and all other Releasees from liability under such claims. This waiver and release does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that California law does not permit to be released by agreement.

I understand that by signing this agreement, I am waiving for My Child any and all claims, of any kind arising out of or attributable to My Child’s participation in the Program, including those claims that may be unknown to me, or which I do not suspect to exist at this time.

WITH THE INTENTION OF WAIVING ALL UNKNOWN AND UNSUSPECTED CLAIMS, I HEREBY EXPRESSLY WAIVE ALL RIGHTS, BENEFITS, AND PROTECTIONS I MAY HAVE UNDER CALIFORNIA CIVIL CODE SECTION 1542, WHICH READS AS FOLLOWS:

“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.”

I shall defend, indemnify, and hold harmless BBBSOC/IE and all other Releasees against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys’ fees, fees and the costs of enforcing any right to indemnification under this agreement, and the cost of pursuing any insurance providers arising out of or resulting from any claim of a third party related to My Child’s participation in the Program, including any claims arising out of my own negligence, the negligence of My Child, or the ordinary negligence of BBBSOC/IE.

THIS AGREEMENT PROVIDES BBBSOC/IE WITH MY ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND I FULLY UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE BBBSOC/IE FOR ANY CLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF MY CHILD’S PARTICIPATION IN THE PROGRAM.

I Agree

Parent/Guardian Signature
Reset Signature

Printed Name of Parent/Guardian

Date Signed

Minor Volunteer Signature
Reset Signature

Printed Name of Minor Volunteer

Date Signed

Relation to Minor Volunteer