Adult Site Based: Volunteer Enrollment Form

Mentor Program

Which of the following Site-Based facilitated programs are you applying for?

Program ID - IE

Please select one:

Corporate PartnerPD PartnerCollege Partner

Name of the corporate company:

Name of the police department:

Name of the college:

Are you a first-generation student?

YesNoA first-generation student is a student whose parent(s)/legal guardian(s) did not attend college.

Volunteer Information

*NOTE: THE BELOW QUESTIONS ABOUT YOUR ETHNICITY, MARITAL STATUS, GENDER/SEXUAL IDENTITY AND RELIGIOUS PRACTICE ARE USED ONLY TO HELP CHOOSE THE MOST BENEFICIAL MATCH FOR YOUR LITTLE. THIS INFORMATION WILL NOT BE CONSIDERED IN DETERMINING WHETHER OR NOT YOU ARE ACCEPTED INTO THE PROGRAM.

First Name

As listed on your Driver's License

Last Name

Preferred First Name

Date of Birth

Please include the slashes above.

Home Address

Line 1

Home Address

Line 2

City

State

Zip Code

Cell Phone

Can we send texts to the cell phone number provided above?

Yes, I agree to receive updates, reminders, and event opportunities text messages from Big Brothers Big Sisters. Agreeing to this isn't a condition of participation in the program. I agree to the Terms of Service and Privacy Policy. Approx. 4 Msgs/Month. Msg & data rates may apply.

Home Phone

Best Time to Call

AnytimeDaytimeEveningWeekend

Personal Email

Alternate Email

Gender

How do you identify?

Sexual Orientation:

What is your sexual orientation?

Personal Pronouns

What pronouns do you use?

Additional Volunteer Information

Race/Ethnicity

Relationship Status

Religious Practice

What is the name of the place you worship?

Type NA (not applicable) if none

If you practice an organized religion, does your place of worship have ministries that focus on mentoring?

YesNo

Do you have Military Service exerience?

Additional Details

Branch, To & From Date, Rank at Discharge, etc.

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

YesNo

If so, when?

If so, where?

How did you hear about Big Brothers Big Sisters?

Referral Detail ID - IE

Do you know any current volunteer Bigs? If so, type their name here.

Would you be interested in hearing of other opportunities of getting involved with Big Brother Big Sisters?

YesNo

Employment & Education Information

Highest Level of Education Completed

Education Years Completed

The total # of years completed in a school setting

Are you currently employed?

YesNo

Employer

Occupation

Employer Address

Employer City

Employer State

Employer Zip Code

Work Phone

Work Extension

Employment Length

May we call you at work?

YesNo

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Cell Phone

Relationship to Volunteer

References

Personal

Reference #1: Friend (acquainted at least 2 years, non-relative)

First Name

Last Name

Cell Phone

Email

Years Known

Relationship to Volunteer

Spousal/Significant Other

Reference #2: Spouse or Significant Other (if not applicable, include additional friend)

First Name

Last Name

Cell Phone

Email

Years Known

Relationship to Volunteer

Professional

Reference #3: Current Employer/Supervisor (if self-employed please include client/business partner or other non-relative)

First Name

Last Name

Cell Phone

Email

Years Known

Relationship to Volunteer

Driver's License & Auto Insurance Information

Do you have a Driver's License?

Driver's License Number

Driver's License State

Driver's License Expiration Date

Experience

Do you have prior experience working with an organization that serves youth in the last 5 years?

Organization Name

Location

Start Date

End Date

Direct Supervisor First Name

Direct Supervisor Last Name

Phone

Email

Description/Duties

Household Information

Are there other people who live in your home?

Full Name

Relation

Age

Interested Volunteer Consent

Please initial each item to complete form.

1. I, the undersigned, hereby give my consent to Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”), to obtain information about me from local, state, and federal law enforcement agencies, motor vehicle departments, court, military agencies, and other public and/or I, the undersigned, hereby give my consent to BBBSOC/IE to obtain information about me from private agencies deemed appropriate in an investigation of my background. I further give consent to the agencies indicated to release any information about me BBBSOC/IE or anyone acting on their behalf.

Initials

2. I, the undersigned, acknowledge and agree that, (1) I am not obligated to perform the volunteer services herein applied for and that the agency is not obligated to assign or actively to seek to assign a Little Brother/Little Sister to me, and (2) as a part of the agency's matching process, additional personal information may be required.

Initials

3. I, the undersigned, understand that all information obtained through the application is the sole property of BBBSOC/IE. I understand that I relinquish my rights to access to this information.

Initials

4. I, the undersigned, understand that BBBSOC/IE may be subpoenaed or otherwise ordered to produce the information included in this application and/or information collected by the agency during the match. I hereby authorize BBBSOC/IE to release such information pursuant to any such subpoena or other order and further agree to release and hold BBBSOC/IE harmless for any and all claims arising from BBBSOC/IE’s release of said information.

Initials

5. I, the undersigned, understand that all information I disclose to BBBSOC/IE, 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

6. I, the undersigned, attest that all of the information provided by me in this application is, to the best of my knowledge, true and accurate, and that I do fully understand all the questions and statements contained herein.

Initials

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

Initials

I have read and understand the above statements.

I Agree

Printed Name of Applicant

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 hereby accept the invitation of Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) 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 my image, name, and biographical information 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; and 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 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.

Initials

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

Initials

I have read and understand the above statements.

I Agree

Applicant Signature
Reset Signature

Printed Name of Applicant

Date Signed

Communication Consent & Agreement

Please initial one of the two boxes below and complete form with your signature and date.

1. I agree to share contact information and communicate virtually and/or electronically with my Little or mentee. Prior to contacting my Little or mentee virtually and/or electronically, I will communicate with my Little or mentee’s parents and/or guardians and with BBBSOC/IE to determine which communication methods or platforms are approved. Such methods or platforms may include, without limitation; telephone, text message, email; video conferencing programs such as Zoom, CommandLink, Google Classroom, and Facetime; and social media platforms such as Instagram, Facebook, Twitter, and TikTok. I may decline to be contacted by certain methods or on certain platforms while agreeing to be contacted by other methods or on other platforms. I agree to not post any photographs or videos of my Little or mentee, or to share any information about my Little or Mentee, on any social networking, media or other online websites.

Initials

2. I do not wish to share contact information or to communicate virtually and/or electronically with my Little or mentee.

Initials

I have read and understand the above statements.

I Agree

Applicant Signature
Reset Signature

Printed Name of Applicant

Date Signed

RELEASE AND WAIVER OF LIABILITY

I, the undersigned, understand that certain risks and dangers may exist in my participation as a volunteer in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) Adult Site Based Program (the “Program”), and that approval of my application 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. Therefore, in exchange for the opportunity to participate as a volunteer 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 participation as a volunteer in the Program, 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 any and all claims, of any kind arising out of or attributable to my participation as a volunteer 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 participation as a volunteer in the Program, including any claims arising out of my own negligence 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 PARTICIPATION AS A VOLUNTEER IN THE BBBSOC/IE 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 PARTICIPATION AS A VOLUNTEER IN THE PROGRAM.

I Agree

Applicant Signature
Reset Signature

Printed Name of Applicant

Date Signed

No Preference	Watch, not Participate
Participate: Individual	Participate: Group
Participate: Individual or Group	Watch and Participate