BIG APPLICATION

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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.

All information in this referral will be treated with confidentiality, dignity, and respect by BBSVC.

Toda la información proporcionada en esta referencia será tratada con confidencialidad, dignidad y respeto por BBSVC

Hidden Fields

Contact ID 18 Character

Enrollment ID 18 Character

Contact Owner ID

Contact Owner Email

Program Type

CBSBSB 17 or younger, CB 18+

This Year

Big Age (calc)

VOLUNTEER INFORMATION | INFORMACIÓN DEL ESTUDIANTE SOLICITANTE

First Name

Nombre de pila

Middle Name

Segundo nombre

Last Name

Apellido

Maiden/Alias

input NA if none

Preferred Name

Birthdate

Fecha de nacimiento

Social Security Number

If you don't have a SSN, put all 0's. We will reach out for more information later.

Gender

Género

How do you identify?

Personal Pronouns

What pronouns do you use?

Race/Ethnicity | Etnicidad

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

What languages do you speak fluently? | Fluido Idiomas

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

Relationship Status

# of Children/Ages

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

Please upload a recent picture of yourself for our records.

If you don't upload a picture, we will use your driver's license picture.

School

Escuela

School Grade

Grado

YOUTH HEALTH INFORMATION

Are there any health concerns (physical, mental, emotional), allergies, and/or medications we need to be aware of to make your experience with us safe and comfortable?

¿Existe algún problema de salud (físico, mental, emocional), alergias y/o medicamentos que debamos tener en cuenta?

CONTACT INFORMATION

Personal Email (do not use a school email)

Correo electrónico personal

Work Email

Correo electrónico del trabajo

Alternate Email

Correo electrónico alternativo

Preferred Email

Correo electrónico preferido

Mobile Phone

Teléfono móvil

Work Phone

Teléfono del trabajo

Work Phone Extension

Home Phone

Teléfono de casa

Alternate Phone

Teléfono alternatino

Preferred Phone

Best Time to Call

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

Home Address

Street Address (incl apartment #’s)

Domicilio (incluido el número de apartamento)

City

Ciudad

State

Estado

Zip Code

Código postal

Mailing address is different from residential address

Street Address

City

State

Zip Code

EMPLOYER INFORMATION

Employment Status

Name of Employer

Occupation

Employment Length (Years)

Employment Length (Months)

Employer Address Line 1

Address Line 2

City

State

Postal Code

Is it okay to call at work?

YesNo

PARENT//GUARDIAN CONTACT INFORMATION | INFORMACIÓN DE CONTACTO DEL PADRE/TUTOR

First Name

Nombre de pila

Last Name

Apellido

Relationship to Youth

Relación con el niño/joven

Street Address

Domicilio

City

Ciudad

State

Estado

Zip

Código postal

Email Address

Dirección de correo electrónico

Cell Phone

Teléfono móvil

Home Phone

Teléfono de casa

Work Phone

Teléfono del trabajo

Who lives in the youth's primary household, and what are their ages?

¿Quién más vive en el hogar principal del joven y cuales son sus edades?

What is the approximate annual household income?

¿Cual es el ingreso anual aproximado del hogar?

This information is optional, but helps us analyze how our programs are run and is kept fully anonymous.

Esta información es opcional, pero nos ayuda a analizar cómo se ejecutan nuestros programas y se mantiene totalmente anónima.

What languages do you speak fluently? | Idiomas fluidos

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

EMERGENCY CONTACT INFORMATION | INFORMACIÓN DE CONTACTO DE EMERGENCIA

Local emergency contact information (NOT a parent/guardian)

Informacion de contacto de emergencia local (no un padre/tutor)

Name

Nombre completo

Relationship to You

Relación con el niño/joven

Street Address

Domicilio

City

Ciudad

Zip Code

Código postal

Email Address

Dirección de correo electrónico

Cell Phone

Teléfono móvil

Home Phone

Teléfono de casa

REFERENCES (Who Have known you for at least 2 years)

BBSVC must be able to contact all references provided; please note that inability to reach these contacts means we will need to get information for additional contacts, which can delay your application process.

1. PARTNER, SPOUSE, OR ROOMMATE (their name and relationship to you)

Spousal/Familial Reference ID

First Name

Last Name

Relationship to you

Years Known

City, State, Zip

Phone

2. EMPLOYER OR SCHOOL (if student), and name of Supervisor or Teacher

Professional Reference ID

First Name

Last Name

Relationship to you

Years Known

Minimum 2 years

City, State, Zip

Phone

3. OTHER REFERENCE, NOT RELATED TO YOU (their name and relationship to you)

Personal Reference ID

First Name

Last Name

Relationship to you

Years Known

Minimum 2 years

City, State, Zip

Phone

VOLUNTEER EXPERIENCES

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

YesNo

When?

Where?

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

YesNo

YOUTH-RELATED VOLUNTEER EXPERIENCE (Name of Organization and Contact Name)

YSO Reference ID

Organization Name

Volunteer Dates

Direct Supervisor First Name

Direct Supervisor Last Name

Years Known

City, State, Zip

Phone

Have you ever actively volunteered?

YesNo

OTHER VOLUNTEER EXPERIENCE (Name of Organization and Contact Name)

YSO Other Vol Exp Reference ID

Organization Name

Volunteer Dates

Direct Supervisor First Name

Direct Supervisor Last Name

Years Known

City, State, Zip

Phone

REFERENCES (Who Have known you for at least 2 years)

1. PARENT/RELATIVE (their name and relationship to you)

Parent/Familial Reference ID

First Name

Last Name

Relationship to you

Years Known

Phone

2. TEACHER

Teacher Reference ID

First Name

Last Name

Years Known

Phone

VOLUNTEER EXPERIENCES

Have you ever actively volunteered with youth?

YesNo

VOLUNTEER EXPERIENCE

HS Big YSO Reference ID

Organization Name

Volunteer Dates

Direct Supervisor First Name

Direct Supervisor Last Name

Years Known

City, State, Zip

Phone

IDENTITY & PERSONAL EXPERIENCES

What is important

about your identity or

you personally that

you’d like for us to

know?

Why do you want to be a Big/Mentor?

Where do you feel most comfortable and able to be yourself? At home, school, or somewhere else?

How do you deal with situations or feelings that upset you?

What do you like to do in your free time? What do you like to do with friends?

What other after-school activities are you/have you been involved with?

What might prevent you from making the time commitment to the program for the whole school year?

PROGRAM AREAS OF INTEREST

Check off what other BBSVC program areas and mentoring opportunities are of specific interest to you:

Mentor Academy: I'd like to be matched with a mentor who can help me explore college & career pathways, life skills, and future focusYouth Leadership Council: I'd like to work with my peers to make a positive difference in my communities

What days of the week can you meet with your Little after school?

Do you anticipate any significant life changes over the next year, or have you had any in the past year?

YesNo

Please explain.

Check off the appropriate box:

Volunteer Applicant is currently in therapy or has been within the past 12 monthsApplicant is NOT currently in therapy or has NOT been within the past 12 months

(Full Name of Volunteer Applicant)

, have not seen a Therapist/Psychologist/Psychiatrist within the past 12 months.

After signing this form, you will be redirected to a consent for release of information from your provider.

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

YesNo

Please explain.

PROGRAM AREAS OF INTEREST

Common heritage or cultural backgrounds	Exploring similar hobbies, goals, or interests
Foster or Kinship Care experiences	Mentor Academy: Exploring college & career pathways, life skills, and future focus
Other	Other common identity factors
Supporting LGBTQ+ youth

Specific hobbies, goals, and interests:

Specific common identity factors:

Other:

Do you have any questions or requests for the Match Support Specialist who will be interviewing you?

SOCIAL MEDIA POLICY

As a volunteer for Big Brothers Big Sisters, and ultimately a representative of our organization, we expect you to adhere to the following guidelines when engaging on any social media or networked platform.

1. Safety of Littles is our number one priority.

It is very important to keep youth safety, youth/family confidentiality, and youth/family dignity in mind when communicating on social media. Do not provide identifying information about your Little or their family. Also, never share the location of a Little on social media channels.

For example do not say, “My Little and I are having a great time at the zoo right now.” Specifying the location could jeopardize their safety. A better option would be to delay the message until after the activity. “I had a great time with my Little at the zoo today.”

2. A signed Talent Release Form is required for photos.

In order to post pictures, video, or any information/content about Littles online, a signed parent/guardian consent form must be on file at the BBSVC office. The parent/guardian of your Little has the right to not sign this release form. Please check with your Match Support Specialist prior to posting anything about your Little.

You may only post pictures of your Little by reposting pictures BBSVC posts first.

2. A signed Talent Release Form is required for photos.

Additionally, even if a Talent Release Form is on file: if your Little demonstrates any verbal or non-verbal objection or discomfort in having photo or video captured, you must always respect their decision; refrain from capturing or sharing content if there is any question about their personal boundaries and comfort levels, even as this may differ day-to-day.

3. You are responsible for your actions and communications. Please exercise sound judgment when using social media at all times.

Anything you post that could potentially tarnish the organization’s image or have a negative impact on the organization is your responsibility. When in doubt about whether or not something is appropriate to post/share, consult with your Match Support Specialist prior to posting/sharing.

Online privacy does not exist. Do not assume that things you publish on a private personal profile cannot be accessed. Do not post or share content/messaging that you would not want to see in the newspaper. Please be aware that, as a volunteer, your interactions with others reflect upon our organization.

4. We recommend that you DO NOT “friend” your Little through social media. Under no circumstance is social networking allowed with Bigs and their Littles under the age of 13.

Under no circumstance is social networking allowed between High School Bigs and their Littles in site-based mentoring.

5. We strongly urge you to keep your profile set to private and closely monitor friend requests and followers on social media.

6. Big Brothers Big Sisters has the right to monitor the social media activities of our Bigs and other volunteers.

If you are seen using social media inappropriately or in a way that is antithetical to the values or mission of BBSVC, your relationship with our organization could be terminated.

Please advise how you are referenced on all social media platforms that you utilize.

Social Media Policy Acknowledgement

I have read and understand the social media guidelines set by Big Brothers Big Sisters of Ventura County. By signing this document, I am pledging to abide by these guidelines when using social media.

CONSENT TO RUN BACKGROUND CHECK & POLICY ACKNOWLEDGEMENTS

I understand that by signing this form:

Youth, parents/guardians, volunteers, Board Members, agency staff, and other participants are not excluded from BBSVC’s programs on the basis of race, religion, national origin, color, gender identity, marital status or marital status of parent, sexual orientation, or [dis]ability. BBSVC’s volunteer selection policy is to first honor the preference of the youth as well as the parents/ guardians who bring their children to the agency for services. Both youth and the parent/guardian must approve the proposed match. Our agency commits to building our spaces with kindness, justice, equity, diversity, inclusion, and respect, in order to best support the youth and families in our programs, build healthy communication between all parties, and encourage stronger mentoring matches.

I understand that by signing this form:

In submitting this application, the volunteer applicant recognizes that Big Brothers Big Sisters of Ventura County (BBSVC) is not obligated to approve or match them with a youth mentee. The applicant also understands that it is agency policy not to disclose justifications for not approving a volunteer - as per youth safety best practices, regardless of the reason - and that BBSVC may disqualify an applicant at any time prior to a mentoring match being activated or introduced.

I understand that by signing this form:

1. The information provided will be used to conduct a background check, to include driving record check, criminal background check, and other records where required by local, state, or federal law for volunteers working with youth.

2.The references listed may be contacted by mail, telephone, or email;

3. Other BBBS agencies, organizations where I have worked or volunteered, and any therapists/psychologists/psychiatrists listed may be contacted as references;

4. As part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations for assignment.

I give my permission to Big Brothers Big Sisters of Ventura County to run a layered background check on me to verify the information I have given to Big Brothers Big Sisters and to collect all the information necessary from business and personal references in order to process my application to ascertain my eligibility as a Big/Volunteer Mentor.

AGREEMENTS

The student must read and adhere to the following agreements for the BBSVC High School Mentor Program:

1. My parent/guardian must give permission for me to participate in the program if I am under 18 years of age.

2. I will be required to provide written references who may be contacted by mail, telephone, or email.

3. I must complete youth safety training before I can be matched with a Little;

4. I must be in compliance with all school district requirements for in-person education, including vaccination status;

5. As a Big/Mentor, the Little(s) consider me a role model. While interacting with Little(s), I agree to conduct myself

responsibly and respectfully and to use appropriate language at all times.

BBSVC High School Student Volunteer

To the best of my knowledge, the information provided is true and correct. I have read and understand the above

statements. I understand the application process and my responsibilities as a BBSVC Volunteer as defined by these statements. I understand that by signing below, I am entering a Volunteer Agreement which obligates me to adhere to the responsibilities as stated above. I also understand that any breach of this Volunteer Agreement may result in being asked to leave the school campus or the ongoing activities and I may not return without BBSVC approval. Further, I understand that any breach of this Volunteer Agreement may result in my being asked to permanently leave the program, which could mean the loss of any earned class/course credits.

Print Name to Sign

Student/Youth

Date

The parent/guardian must read and adhere to the following agreements for their student to participate in

BBSVC’s High School Mentor Program:

I willingly give my consent for Big Brothers Big Sisters of Ventura County (BBSVC) to obtain the following school records from the Office of the Registrar: Transcript, Current GPA, Class Schedule, and Immunization Record. I understand that this is a permanent release unless I cancel the request in writing.
I consent to my child/the above named student to be transported by BBSVC staff for regular program-related activities in BBSVC-approved vehicles.
I consent for all purpose to the reproduction and/or use of photographs of my child (with or without the use of their name) by Big Brothers Big Sisters of Ventura County and by any nominee or designee of Big Brothers Big Sisters (including any agency, client, periodical or other publication) in all forms and media and in all manners, including social media, advertising, trade, display, editorial, art, and exhibition. In giving this consent, I release Big Brothers Big Sisters, their nominees and designees from liability for any violation of any personal or proprietary right I may have in connection with such reproduction, or use. I approve the forgoing and waive any rights in the premises.

Parent/Guardian of the HS Mentor Program Applicant

As the parent/legal guardian of the above named student, I give my permission for them to participate in the BBSVC High School Mentor Program. I am the parent/guardian of the minor named above and have the legal authority to execute the above consent and release.

Print Name to Sign

Parent/Guardian

Date

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