WPM 18+ Participant Enrollment Form

Mentee Information

First Name

Last Name

Preferred First Name

Date of Birth

Please ensure the YEAR is correct.

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 Mentee Information

Race/Ethnicity

Religious Practice

How did you hear about Big Brothers Big Sisters?

Referral Detail ID

Employment & Education Information

Highest Level of Education Completed

School Name

Are you currently employed?

YesNo

Employer

Occupation

Work Phone

Work Hours

May we contact you at work?

YesNo

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Cell Phone

Relationship to Mentee

Mentee Pre-Enrollment Questionnaire

Prior to your in-person interview, we would like you to answer the questions below. The information you give will also help us make a better match for you and assure we can support you during your involvement with our programs.

2. What is your primary language?

Do you speak any languages other than English?

YesNo

What other language do you speak?

3. Are you experiencing any physical or mental health problems?

Yes

No

Please describe:

Additional Information

What are your short term and long term professional goals?

Do you currently have a mentor or a close network of support? If so, how do they encourage you to achieve your goals?

What do you hope to gain from this experience?

Participant Consent

Please initial each item to complete form.

1. I, the undersigned, understand that all information is confidential and will not be released without your permission. Information may be shared only with the teachers, counselors, school or partner staff, BBBS staff and volunteer mentors involved in the matching process.

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2. 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 prospective or matched Big Brother/Big Sister and I hereby consent to such disclosure.

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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 this information.

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4. I, the undersigned, understand that all information received will be kept confidential, within the agency’s limits of the law. However, California law does require that all professionals who work with families and children under the age of 18 report known and suspected incidents of child abuse, as well as threats of harm to oneself or others.

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5. I, the undersigned, authorize my school/Hope Builders to release the following regularly reported information to BBBSOC/IE on a quarterly basis or as requested, including such information as grade point averages, transcripts, school attendance rates, grade advancement information, graduation information and noted social and academic information (i.e. relevant behavior reports or counselor/social worker feedback). All identifying information will be held in confidence by BBBSOC/IE staff and volunteers.

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6. I, the undersigned, give permission:
(1) To participate in the BBBBSOC/IE Workplace Mentoring 18+ Program
(2) To complete program questionnaires containing questions about school, home life, and personal interests
(3) To participate in all assessments and evaluations in regards to the program

Initials

I have read and understand the above statements.

I Agree

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 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.

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

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I have read and understand the above statements.

I Agree

Participant Signature
Reset Signature

Printed Name of Participant

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 mentor. Prior to contacting my mentor virtually and/or electronically, I will communicate with my mentor 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 mentor, or to share any information about my mentor, on any social networking, media or other online websites.

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

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I have read and understand the above statements.

I Agree

Participant Signature
Reset Signature

Printed Name of Participant

Date Signed

RELEASE AND WAIVER OF LIABILITY

I, the undersigned, understand that certain risks and dangers may exist in my participation as a mentee in the Big Brothers Big Sisters of Orange County/Inland Empire (“BBBSOC/IE”) Workplace Mentoring 18+ 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 mentee 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 mentee 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 mentee 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 mentee 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 MENTEE 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 MENTEE IN THE PROGRAM.

I Agree

Participant Signature
Reset Signature

Printed Name of Participant

Date Signed