Big Brothers of the Triangle Volunteer Application

Hidden Fields - Do not delete

Contact ID

Enrollment ID

Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.

Basic Information

First Name

Middle Name

Last Name

Maiden/Alias

input NA if none

Preferred Name

Birthdate

Social Security Number

Gender

How do you identify?

Personal Pronouns

What pronouns do you use?

Who referred you to our program?

Race/Ethnicity

American Indian or Alaska Native	Asian - Chinese
Asian - Filipino	Asian - Indian
Asian - Japanese	Asian - Korean
Asian - Other	Asian - Vietnamese
Black or African American	Hispanic - Cuban
Hispanic - Mexican,Mexican American,Chicano	Hispanic - Other Latinx or Spanish origin
Hispanic - Puerto Rican	Middle Eastern or North African
Pacific Islander - Chamorro	Pacific Islander - Native Hawaiian
Pacific Islander - Other	Pacific Islander - Samoan
White or Caucasian	Other
Prefer not to say

Tribal & Regional Corporation Affiliations

Nationality

To select multiple, hold CTRL/CMD and click.

Relationship Status

Do you have a driver's license?

Driver's License Number

Driver's License State

Driver's License Expiry

Please upload a copy of your license

File can be a screenshot, PDF, or picture

Auto Insurance Effective Date

Auto Insurance Company

Please upload a copy of your auto insurance.

File can be a screenshot, PDF, or picture

Contact Information

Personal Email

Work Email

Alternate Email

Preferred Email

Mobile Phone

Work Phone

Work Phone Extension

Home Phone

Alternate Phone

Preferred Phone

Best Time to Call

In general, do you prefer to be contacted by email or phone?

Mailing Address

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Mailing address is different from residential address

Physical Address

Street Address

City

State

Zip Code

Emergency Contact Information

Name

Phone

Relationship

Employer Information

Employment Status

Name of Employer

Occupation

Employment Length (Months)

Employment Length (Years)

Employer Address Line 1

Address Line 2

City

State

Postal Code

Is it okay to call at work?

YesNo

Additional Information

Which program are you applying for?

Level of Education

Year Degree Obtained

Education Years Completed

School Attended

Have you served in the military?

How would you describe yourself, in terms of participation in events, activities, or sports?

Which activities do you enjoy more?

How did you hear about Big Brothers Big Sisters?

Referral Detail ID

References and Background Check

Previous Experience

Have you previously applied to be or served as a Big here or anywhere else?

YesNo

When?

Where?

Have you ever been involved with Big Brothers Big Sisters in a capacity other than a Big?

YesNo

When?

Where?

Have you ever been denied acceptance or released from service as a volunteer or employee or another Big Brothers Big Sisters Program for another youth-serving organization?

YesNo

When?

Where?

Have you ever actively volunteered or worked with youth before as a Big or otherwise?

Volunteer Experience

Organization Name

Location

Start Date

End Date

Direct Supervisor First Name

Direct Supervisor Last Name

Phone

Email

Years Known

Reason for Leaving

Please provide at least three references below including:

Your spouse or domestic partner OR a family member if you do not have a spouse, partner, or significant other.
Current or former employee or co-worker you have known for at least one year or someone from your school if you are a student
A friend or neighbor you have known for at least two years

Spousal/Familial Reference

Spousal/Familial Reference ID

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Professional Reference

Professional Reference ID

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Minimum 1 year

Personal Reference

Personal Reference ID

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Minimum 2 years

I consent to and understand that:

The references and youth-serving organization(s) I listed may be contacted by mail, telephone, email, or in person;
The information I provided may be used to conduct a background check, to include a search of public domain records, driving records check, juvenile and adult criminal history check (see attached authorization), military records, and other records where required by local, state, or federal law for volunteers working with youth;
I am in no way obligated to perform any volunteer services;
The BBBS agency is not obligated to match me with a youth and may deny my application or close my match at any time, and to protect all participants’ confidentiality, BBBS is not required to disclose reasons for doing so;
Other BBBS agencies and youth organizations where I have worked or volunteered may be contacted as references;
As part of the enrollment processes, I will be required to provide additional personal information, including completion of an in-person interview;
I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law.
I understand that detailed accounts of child abuse or neglect, past or present, will be reported to proper authorities;
I understand that certain relevant information about me will be discussed with the parent/guardian of a child who is a prospective match (this might include demographic information, information relevant to parent/child preferences, and any information relevant to a child’s safety or well-being);
It is my responsibility to update the agency if any of the information I provide on this application, in my interview, or any other information provided during the enrollment process changes (i.e. address, phone number, auto-insurance, new criminal charges, etc.)
I agree to complete questionnaires throughout my time in the program to evaluate and improve program services;
I agree to timely communication and follow-up with all agency staff as required by the agency.

I accept the terms and conditions

Pre-Interview Questionnaire

Prior to your in-person interview, please answer the questions below. The information you provide will also help us make a better match for you and assure we can support you during your involvement with our program. Please note that you will have an opportunity to discuss these questions and your responses more thoroughly during your in-person interview.

Which county are you enrolling in?

Agency Location ID

Do you have any concerns about your ability to fulfill the time commitment required of mentors?

YesNo

Do you anticipate any significant life changes over the next year or have you had any this past year? (ie. job or schedule changes, moving, new family member, etc.)

YesNo

Please describe:

Have you ever been accused, arrested, charged, or convicted of a crime?

YesNo

Please describe:

Have you had any driving citations and/or moving violations in the past five years?

YesNo

Please describe:

Do you have guns, ammunition, or other weapons in your house?

No GunsGuns Secured

Agency Weapons Policy

As a volunteer Big Brother/Big Sister, I agree to keep inaccessible to my Little, all guns/weapons that may be in my home or in any mode of transportation. I will do this by assuring that the following precautions are taken:
·         All guns/weapons in my household will be unloaded, locked-up, and inaccessible to my Little.
·         All guns in my household are registered when legally required.
·         Any bullets or ammunition in my household will be locked-up separately from the guns/weapons and will be inaccessible to my Little.

·         I will not show any guns/weapons or bullets/ammunition to my Little or discuss their existence or their whereabouts with my Little. My Little will have no knowledge of guns/weapons being stored in my home.

I acknowledge that if there is a gun/weapon in my household, even if I am not the owner, I am responsible for taking these safety measures throughout the duration of my match. I further understand that, if I do own a gun, it is permitted, licensed and registered and handled in compliance with all applicable state and federal laws. I understand that this agreement will be discussed with the Little’s parent or guardian in the match proposal call, and will be monitored by my Match Support Specialist in follow-up calls.

What languages do you speak fluently? (select all that apply)

African Languages (Swahili, Bantu)	American Sign Language
Arabic	Asian: Other
Chinese	Creole
Dutch	Eastern European (Czech, Slovak)
English	French
German	Greek
Hebrew	Hmong
Indian (Hindi, Punjabi)	Italian
Japanese	Keres (West)
Korean	Lao
Nordic	Persian
Portuguese	Russian
Spanish	Turkish

Please list any counties and states that you have lived in aside from your current address in the past five years.

City/State

From

Please provide the name, age, and relationship to you for anyone else residing in your home.

Name

Birth Date

Release of Information Authorization for Background Check

By signing below, I agree to inform Big Brothers Big Sisters staff of any contact that I have with law enforcement at any time while I am matched in the program (this includes speeding violations). I understand that Big Brothers Big Sisters reserves the right to conduct a background check on me at any time during my program participation and will conduct one a minimum of every 3 years that I am matched in the program. Staff will use professional judgment on whether any accusations or charges warrant closure of the match.

I consent to the preparation and release of background reports to Big Brothers Big Sisters of America and its designated representatives.

Confidentiality and Digital Platform Policies

As a volunteer Big Brother or Big Sister, I understand that personal information about the Little I am matched with, and/or his/her family, should be held in confidence. Any information that I may share with people I know will be limited to information about the types of activities that my Little and I do together and will not reveal personal information that my Little shares with me. When speaking to people I know about my Little, I will only use his/her first name and will not identify where my Little lives. I understand that this confidentiality obligation does not apply to communications with my Match Support Specialist or other Big Brothers Big Sisters agency staff whom I might speak with regarding any circumstances of my match.

I have read the above statement and understand Big Brothers Big Sisters of the Triangle’s policy regarding confidentiality of my Little’s personal information and identity. I agree that I will fully adhere to the terms of this policy as a condition of my participation with the agency, and understand that failure to comply with this policy may result in a severance of my relationship with the agency. This statement shall remain in full force and effect for the entire duration of my involvement with Big Brothers Big Sisters of the Triangle and thereafter.

I have read and understand the above information provided to me regarding Big Brothers Big Sisters' confidentiality policy. I agree by the conditions set forth.

RELEASE of IMAGE/NAME/VOICE for PROMOTIONAL PURPOSES

I consent to use images and consent to use my name in promotional materials for Big Brothers Big Sisters of America.I do not give consent to use above mentioned images and further consent to use my name in any promotional materials.

Virtual Platform

Big Brothers Big Sisters of America has developed a digital platform to help Bigs and Littles stay in touch more easily in a safe and secure way. Participation requires your permission.

I consent, should I be matched, to having contact with my Little through Big Brothers Big Sisters' digital platform.

Publicity and promotional materials for Big Brothers Big Sisters are conducted in a variety of forms. May we use your name, image, likeness, appearance, or basic biographical information in these materials?

Media Consent and Release

I irrevocably consent to any and all uses and displays of my name, image, likeness, appearance, basic biographical information, audio/video recordings, writings, artwork, and the like, in original form or in modified form, in whole or in part, in, on, or in connection with merchandise, advertising, publicity, marketing, fundraising, and the like, in printed or electronic media, of any type, throughout the world at any time by Big Brothers Big Sisters of America and [BBBSA affiliate] in their sole discretion, and by any of their affiliates, successors, partners, sponsors, donors, any entities or persons with whom they conduct any public relations, marketing, or fund raising of any type, and any other authorized third parties, without further consent from me, without any royalty, payment, or other compensation to me, and with the release and waiver of any claims, actions, damages, losses, costs, expenses and liability of any kind arising from any such use (the “Released Material”).

In consideration of the mutual promises made herein, and for other good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I hereby grant to BBBSA and its affiliates the right to use the Released Material as BBBSA and/or its affiliates may desire, in all media now existing or hereafter created and in all variations and forms including, but not limited to, internal or external publications or productions, informational or recruitment materials, marketing materials, fundraising materials, televised photography and/or recordings, advertisements, Public Service Announcements, and/or online and social media sites. The use of this information shall be at the sole discretion of BBBSA and/or its affiliates.

I further grant to BBBSA and its affiliates the absolute right to use the Released Material in whole or in part, alone or in conjunction with any other image, name, writings or reproduction, in color or otherwise, for art, advertising, business, trade, or any other lawful purpose whatsoever, in perpetuity throughout the world.

I understand and agree that all materials created by BBBSA and/or its affiliates that use the Released Materials are the property of and are owned by BBBSA, and that I cannot authorize their use by any other party. I further understand that BBBSA may authorize their use by a third party. I hereby irrevocably transfer and assign to BBBSA my entire right, title and interest, if any, in and to the Released Materials and all copyrights in the Released Materials arising in any jurisdiction throughout the world, including the right to register and sue to enforce such copyrights against infringers.

I acknowledge and agree that I have no right to review or approve the Released Materials before they are used by BBBSA and/or its affiliates, and that BBBSA has no liability to me for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSA’s and/or its affiliates’ editing, alteration or use of the Released Materials. BBBSA has no obligation to use the Released Materials or to exercise any rights given by this Consent and Release Form.

I hereby release BBBSA and its affiliates, employees, and agents, as well as any partner companies, from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSA’s exercise of the rights hereby granted, and/or with the appearance or the Released Materials in any publication or production. These include, without limitation, claims for compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever.

Consent to Release Media Footage (please check one):

I hereby grant permission to recognized broadcast media and to Big Brothers Big Sisters to record footage of me. I understand this footage may be aired during upcoming newscasts and/or used for recruitment purposes for Big Brothers Big Sisters.I DO NOT grant permission to recognized broadcast media and to Big Brothers Big Sisters to record footage of me.

Consent to Release Photographs (please check one):

I hereby grant permission to Big Brothers Big Sisters to use photographs of me. I understand this footage may be used in printed materials (e.g. brochures, newspapers) and/or on Big Brothers Big Sisters websites, or otherwise used for recruitment purposes for Big Brothers Big Sisters

I DO NOT grant permission to Big Brothers Big Sisters to use photographs of me.

Application Acknowledgement

I understand that this is an application for a volunteer opportunity and is not a promise or commitment by Big Brothers Big Sisters.

I certify that all information I have provided or will provide to Big Brothers Big Sisters, including this application, is true, accurate, and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would affect my application for a volunteer position. I understand that information contained in my application will be verified by Big Brothers Big Sisters. I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant or my termination as a volunteer.

At any time while involved with the Big Brothers Big Sisters program, I agree to immediately inform my Big Brothers Big Sisters contact person of any and all infractions, violations, charges, and convictions related to any civil, domestic, or criminal matters. I understand that BBBS staff needs to be fully informed to provide the best guidance or support possible.

I have answered these questions honestly and completely to the best of my knowledge.

Contact Information