BBBS Volunteer Application

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.

Hidden Fields

Contact ID 18 Character

Enrollment ID 18 Character

Contact Owner ID

Contact Owner Email

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?

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

Auto Insurance Policy Duration

6 months12 months

Auto Insurance Broker/Agent

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?

Extra information to map to interview details

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

Level of Education

Year Degree Obtained

Education Years Completed

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

YSO Reference ID

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.

Do you have any concerns about your ability to fulfill the year 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

Volunteer Firearms and Weapons Guideline

While some adults possess weapons for hunting and/or protection purposes, it is the policy of Big Brothers Big Sisters of Licking & Perry Counties that all agency volunteers agree:

1. To inform the agency of the ownership of weapons or the presence of weapons in the home. BBBS staff will discuss the ownership of weapons during the volunteer’s interview and/or home assessment, and update that status for the life of the match. For purposes of this policy, “weapons” may include all firearms, handguns, zip guns, knives (except for kitchen knives and small pocket knives not used or intended for use as a weapon or to inflict bodily injury) and explosive devices.

2. To ensure that weapons and ammunition are inaccessible to the child assigned to you by the agency and to any other child participating in a BBBS activity, while the child is under your supervision. The means of ensuring the inaccessibility will be discussed during the interview and/or home visit.

3. To adhere to the policy that a volunteer will not carry a concealed handgun at any time while accompanying the child assigned to you by the agency or accompanying any other child participating in a BBBS activity (with the exception of law enforcement officers who are required to carry a weapon at all times and have received prior approval from the agency).

4. To understand that the agency will disclose to the parent or guardian of the child assigned to you by BBBS the agency’s weapons policy and the volunteer’s admission of weapon ownership or the presence of a weapon in the home. The parent/guardian and the volunteer will sign an acknowledgement of the ownership of a weapon and the form will be kept in the child’s permanent file.

5. To obtain permission from the child’s parent/guardian and from the agency before engaging in any activity in which a weapon may be used with the child assigned to you by the agency or with any other child participating in agency activities.

6. To abide by any other policy or procedures that the agency may put into effect regarding weapons.

7. Big Brothers Big Sisters of Licking & Perry Counties, along with the State of Ohio require that a child under the age of 18 to participate in a gun safety course prior to using a firearm. We ask that a Volunteer provide their match support contact with a copy of the completed gun safety course prior to engaging in activities with weapons.

As a volunteer, I understand and agree to abide by the Weapons Policy of Big Brothers Big Sisters of Licking & Perry Counties . I do / do not own a weapon. A weapon is / is not present in my household. I agree to keep any weapons and ammunition inaccessible to the child assigned to me by Big Brothers Big Sisters of Licking & Perry Counties while he/she is in my custody, unless on a specifically approved match activity, such as hunting trip, a gun safety course, etc.earms and Weapons Guidelines

I agree to keep any weapons and ammunition inaccessible to the child assigned to me by BBBS while he/she is in my custody, unless on a specifically approved match activity, as described above.

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

VOLUNTEER RELEASE AND CONSENT FORM

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NOTE TO BIG: As a continued volunteer your Background screening has to be updated every 3 years. The following permission form will be submitted to law enforcement agencies as a routine and usual part of our Big Brothers Big Sisters update process and used for our purpose only. Please provide information requested, sign the form, and return it with your Big Brothers Big Sisters office.

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I, signed below, certify that, as of the date I listed below, have made application to become a volunteer with the Big Brothers Big Sisters Program. I further certify that I have given that agency permission to seek a copy of my arrest record from the City of Newark, Ohio Police Department, and/or the City of New Lexington, Ohio Police Department, and/or Licking County Sheriff’s Office, and/or the Perry County Sheriff's Office and/or the Ohio State Highway Patrol and/or the Ohio Bureau of Criminal Investigation and/or any other law enforcement agencies. I do hereby release these law enforcement agencies and all individuals connected therewith from all liability. I further certify that I have given my permission for the agency to seek a copy of my arrest record at any time during my involvement as a volunteer with the agency.

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

CONFIDENTIALITY STATEMENT

Big Brothers Big Sisters of Licking and Perry Counties (BBBSLP) respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.

Limits of Confidentiality:

Information will be released to other individuals or organizations only with the client or volunteer’s written consent.

Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteers request otherwise.

For purposes of program evaluation, audit, or accreditation, and with prior approval of the Board of Directors, certain outside bodies, such as Big Brothers Big Sisters of America, may have access to client and volunteer records. These outside bodies shall be required to use information only for the purpose(s) stated in the approval action of the Board of Directors.

Agency volunteers, student interns, and part-time temporary employees may have access to client and volunteer files upon authorization by the Executive Director, the Program Director, or designee(s). These individuals shall be required to adhere to the agency’s Confidentiality Policy. A Confidentiality Statement must be signed by these individuals prior to accessing confidential information.

Information shall only be provided to law enforcement officials and the courts pursuant to a valid and enforceable subpoena.

Information shall be provided to the agency’s legal counsel in the event of litigation or potential litigation involving the agency.

State law mandates that suspected child abuse be reported to the Licking County Department of Job and Family Services.

If an agency worker receives information indicating that a client or volunteer may be dangerous to himself/herself or to others, necessary steps may be taken by the appropriate party. This may include a medical referral or report to law enforcement authorities.

At the time that a child or volunteer is considered as a match candidate, information is shared between prospective match parties. The information about the volunteer may include: age, sex, race, religion, interests, hobbies, marriage/family status, sexual orientation, living situation, reason for applying to the program, and summary of why selected for the match. Information about the child may include: age, sex, race, religion, interests, hobbies, family situation, summary of clients’ needs, and expectations for match participation.

Safekeeping of Confidential Records:

Copying, removing, allowing unauthorized access to any agency documents, files, mailing lists, or any form of distribution of client, volunteer, or personnel/staff information is not allowed.

Case records shall be kept in a locked container.

Violations of Confidentiality:

A known violation of the agency policy on confidentiality by a staff member shall result in disciplinary action.

A violation of the agency policy on confidentiality by someone other than a staff member shall result in the offense being reviewed by the Board of Directors.

Clients or volunteers may request to view their individual record during regular business hours. Requests should be made, in writing, to the Agency’s Program Director. Employees may request to view their individual record. Requests should be made, in writing, to the Agency’s Grants & Operations Director.

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.

Social Media Guidelines for Volunteers

Big Brothers Big Sisters of Licking & Perry Counties

Guidelines for Online Social Networking

Big Brothers Big Sisters of Licking & Perry Counties recognizes that online social networking (Facebook, Instagram, Twitter, LinkedIn, Blogs, etc.) has become a very popular communications tool and that many of our Big Brothers/Sisters and Little Brothers/Sisters use these websites. In general, personal use of social networking sites is typically for communications between peers, including friends and family. BBBS wants to reiterate that the match relationship is that of a mentor in addition to a friend.

Not all social networking sites are designed to support a mentoring relationship.

· Do not participate in any online communication with/about the Little unless discussing this with the Parent/Legal Guardian and have approval.

· If posting on social media in relationship to your Big Brothers Big Sisters match by the Parent/Legal Guardian, Volunteer Big or Little, you are required to tag the agencies Facebook, Instagram and/or Twitter account (depending on what type of social media you are posting to) so that the agency can follow along with the post.

· The agency or Volunteer Big are never to post any pictures of the match or Little online unless verbal approval has been provided by the Parent/Legal Guardian.

· Never post the last name of the Little, Parent/Legal Guardian, Volunteer Big or agency staff.

· Never post any identifying information about the Little (i.e. child’s home address, school the Little attends, where the parent works, etc.)

· Volunteer Bigs must make sure that their post setting has been set to private, so that only people approved by the Volunteer Big can view their online content. Volunteer Bigs must ensure that BBBSLP and the Parent/Legal Guardian have approved anything that will be posted relating to the match.

· Volunteer Big will honor confidentiality guidelines within the match; be cautious when posting detailed information about conversations with the Little, the Parent/Legal Guardian or with agency staff. Posting generalized information or status updates is typically appropriate, but lengthier posting or blogs containing in-depth information should be approved by the Parent/Legal Guardian and by the agency staff prior to posting.

· Volunteer Big needs to be aware of other postings on any social media page that are not BBBSLP related or are inappropriate for minors. Know that as a BBBS volunteer, they are a role model at all times. Volunteer Bigs will ensure that all contents are appropriate and kid-friendly, in case the Little or Little’s family were to read their social networking page.

· When in doubt about whether or not something is appropriate to post, Volunteer Big will consult with BBBSLP Match Support Specialist prior to posting.

The undersigned Parent/Legal Guardian and Volunteer Big, as well as the Little, have read and understand the Guidelines for Online Social Networking .Failure for a Volunteer Big and Parent/Legal Guardian to adhere to these guidelines may result in the termination of a match.

I consent to use images and consent to use my name in promotional materials for Big Brothers Big Sisters of America.

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.

I have read this Consent and Release Form completely. I fully understand what it means, and I agree to its terms. I have not been offered any additional consideration or enticement, nor have I been coerced to sign this document. I am voluntarily signing it for the purposes and considerations described.

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