Big Brothers Big Sisters Volunteer 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.

Basic Information

Contact ID 18 Character

Contact Owner ID

Contact Owner Email

First Name

Middle Name

Last Name

Maiden/Alias

input N/A if none

Preferred Name

Birthdate

Social Security Number

Gender

How do you identify?

Sexual Orientation

Write In Sexual Orientation

If you selected "Write In" above, enter it here

Personal Pronouns

What pronouns do you use?

Race/Ethnicity

American Indian or Alaska NativeAsian - ChineseAsian - FilipinoAsian - IndianAsian - JapaneseAsian - KoreanAsian - OtherAsian - VietnameseBlack or African AmericanHispanic - CubanHispanic - Mexican,Mexican American,ChicanoHispanic - Other Latinx or Spanish originHispanic - Puerto RicanMiddle Eastern or North AfricanOtherPacific Islander - ChamorroPacific Islander - Native HawaiianPacific Islander - OtherPacific Islander - SamoanPrefer not to sayWhite or Caucasian

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. If you do not have auto insurance, please upload your Driver's License again.

Who is the policy-holder of your auto insurance?

MyselfSignificant otherSpouseParentOther

Please describe:

Residential History

How long have you lived in the area?

Please list all other counties/cities and states you have lived during the past 15 years. (Please include deployment, college experience, study abroad, etc.)

City/State

From

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 County

Mailing address is different from residential address

Where will you be volunteering?

Greater Richmond (Richmond, Henrico, Chesterfield, surrounding areas)Greater Virginia Peninsula (Hampton, Newport News, Williamsburg, surrounding areas)Hampton Roads (Virginia Beach, Chesapeake, Norfolk, surrounding areas)Tri-Cities (Hopewell, Petersburg, Colonial Heights)

Physical Address

Street Address

City

State

Zip Code

County

Emergency Contact Information

Name

Phone

Relationship

Employer Information

Name of Employer or School

Enter N/A if no employer or school

Occupation

Employment Length (Months)

Employment Length (Years)

Employer Address Line 1

Address Line 2

City

State

Zip Code

Is it okay to call at work?

YesNo

Additional Information

Level of Education

Year Degree Obtained

Have you served in the military?

How did you hear about Big Brothers Big Sisters?

Referral Detail ID

Page 2

Questionnaire

Why do you want to become a mentor?

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

Which activities do you enjoy more?

Do you speak any languages other than English?

Spanish	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	Nordic
Persian	Portuguese
Russian	Turkish
Lao

Religion

Do you have any weapons/guns or ammunition in your home?

No GunsGuns Secured

Do you have any pets?

YesNo

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

YesNo

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

What was the charge?

In what county/city & state did it occur?

When did it occur?

What was the court outcome of the charge?

Please list any significant life changes you had in the past year or expect over the next 15 months. For example, job change, school admission, move, etc.

Are you willing to mentor a child in a high crime neighborhood?

YesNo

Are you currently volunteering with any other organizations?

Please list:

Please list any involvement with other civic, professional or social organizations. For example, fraternities/sororities, churches, Rotary, etc.

What days and times are you generally available to meet with a Little in our program?

Previous Experience

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

When?

Where?

Interest Poll

Please check off your interests:

AnimeArtBakingBaseballBasketballBike ridingBoard gamesBowlingCheckersCheerleadingChessComputersCookingCraftsDancingDodgeballDolls/Action figuresExerciseFashion/BeautyFishingFootballGolf/Mini golfHistoryKickballMartial ArtsMathMusicReadingRock climbingScienceSewing/KnittingSingingSkating/SkateboardingSoccerSwimmingTennisTV/MoviesVideo games

Agency Policy on All Mentoring Volunteers

In determining an applicant’s suitability for our program, factors such as the health, personality, behavior, employment and educational status of the individual are taken into consideration. An interview with a staff member is part of the application process and is designed to establish a profile of you and your interests. Additional information about you will be obtained from the character references you supplied, from background checks performed through the Child Abuse Registry, the State of Virginia Criminal Records Check and the Division of Motor Vehicles. Big Brothers Big Sisters Services, Inc. may also make use of other information concerning an applicant acquired by the agency from other persons, agencies, or other sources that may come to its attention.

Excepting any disclosures to which the agency is subject as a matter of law, all information received concerning an applicant will be treated as confidential and will not be disclosed to anyone except in connection with the administration and operation of the agency and its Big Brother Big Sister program.

The undersigned acknowledges and agrees that: he/she is not obligated if called upon, to perform the services herein applied for, and that the agency is not obligated to accept him/her as a volunteer or to assign, or actively seek to assign him/her a Little Brother/Little Sister.

All information obtained about any volunteer and any information pertaining to a match between a volunteer and a child are the property of and will remain the property of our agency. An applicant has no right to obtain, review or copy any such information or files. Applicants who are not accepted will not necessarily be told of the specific reasons for their non-acceptance; as to do so could jeopardize the screening policies of the agency. The applicant will be informed by letter of his/her non-acceptance by the Executive Director.

In the event a match is made, the undersigned also acknowledges and agrees that: the parent(s) or guardian of the child, the volunteer himself/herself, or the school has the right to terminate the relationship. If the agency determines the best interests of the child would be served by the termination of the match, then the agency reserves the right to, and in sole discretion may, terminate the services of the volunteer. Further, in the event of such termination by the professional staff, Big Brothers Big Sisters Services, Inc. is not obligated to provide the volunteer with the specific reason(s) for such termination.

NOTICE: By signing this application you are hereby advised that any and all suspicions of child abuse and/or sexual misconduct involving children, whether physical or verbal, will immediately be reported to the appropriate authorities and any individual found guilty of these offenses will be prosecuted to the fullest extent of the law.

The undersigned certifies that all information included in this application is true and correct to the best of their knowledge.

I authorize Big Brothers Big Sisters Services, Inc. to contact my employer and the individuals I have named as personal references.

I authorize Big Brothers Big Sisters Services, Inc. to contact any other BBBS agencies or named Youth Serving Organizations I have applied to or worked with in the last 5 years to obtain reference information.

I agree to advise Big Brothers Big Sisters Services, Inc. immediately of any changes in the information provided or representations made in this application.

I COMMIT TO MENTORING A CHILD FOR A MINIMUM OF 1 YEAR (12 MONTHS) ON A CONSISTENT BASIS FROM THE TIME THE MATCH IS MADE.

I agree

The references I list may be contacted by mail, telephone or email.

I agree

This application no way obligates me to perform any volunteer services.

I agree

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

I agree

Big Brothers Big Sisters Services, Inc. is not obligated to match me with a youth.

I agree

Prior to making any professional determinations on acceptance into program, we will be asking you to provide additional personal information.

I agree

Please enter today's date to acknowledge you have read the Terms and Conditions above.

References

Please provide at least four references. A reference from a Spouse or Significant Other is required. Substitute a family member if no Spouse/Significant Other.

Spousal/Familial Reference

Spousal/Familial Reference ID

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Professional Reference

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Personal Reference

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Personal Reference

First Name

Last Name

Email

Phone

Relationship to you

Years Known

Have you held a volunteer or paid position where you worked with children in the last five years? (for example counselor at a camp, babysitting, nannying, coaching, etc.)

Volunteer Experience

Organization Name

Location

Start Date

End Date

Direct Supervisor First Name

Direct Supervisor Last Name

Phone

Email

Years Known

Reason for Leaving

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Media Consent and Release

I hereby accept the invitation of Big Brothers Big Sisters of America (BBBSA) and Big Brothers Big Sisters Services, Inc. to appear and be identified in print in any BBBSA or BBBS Services, Inc. publication or production, or grant the right to use the image of a volunteer as specified below.

I hereby grant to BBBSA and its affiliates the right to use this image, name, and biographical information as they may desire, in all media and in all forms including, but not limited to, publications, any televised photography and recordings.

In consideration of $0 to me paid, I hereby grant to BBBSA and BBBSA affiliates the absolute right to use this image made through BBBSA 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, business, trade, or any other lawful purpose whatsoever, in perpetuum.

I hereby release BBBSA and BBBSA affiliates from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSA’s and BBBS Services, Inc.’s exercise of the right hereby granted, with my (or minor child’s) appearance 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.

Publicity and promotional materials for Big Brothers Big Sisters are conducted in a variety of forms. By selecting below I authorize Big Brothers Big Sisters to identify me in the media as a Big Brother or Big Sister using my name and likeness. I also give permission for the use of other forms of media including but not limited to written word, photo, video, social media, and voice recording.

I consent to Big Brothers Big Sisters using my image and likeness in the following formats:

Photo VideoSocial MediaOpt Out

Confidentiality Policy

Big Brothers Big Sisters Services, Inc. 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.

All records are considered the property of the agency and not the agency workers or clients or volunteers themselves. Records are not available for review by the clients or volunteers.

Information will be released to other individuals or non-BBBS organizations only with the client or volunteer’s written consent or with the understanding that the respective parties have agreed to adhere to this confidentiality policy.

Big Brothers Big Sisters Services, Inc. has permission to use the client or volunteer’s name and photograph for the purpose of promoting the agency. Such use may occur before, during, and/or after participation in the program. Big Brothers Big Sisters Services, Inc. and their nominees and designees are hereby released from any obligation or liability in connection with any personal or proprietary rights as a result of the sale, reproduction or use of the above-referenced identifying information.
For purposes of program evaluation, audit, or accreditation, and with the 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.
Members of the Board of Directors or evaluators appointed by the board have access to client files upon authorization of the Board of Directors.
Information shall only be provided to law enforcement officials of the courts pursuant to a valid and enforceable subpoena.
Information shall be provided to an 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 appropriate authorities (Virginia Department of Child Protective Services Hotline 1-800-552-7096).
If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include medical referral or report to the local law enforcement authorities.
At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. The information about the volunteer may include such items as: age, sex, religion, interests, hobbies, marriage, family status, sexual orientation, living situation, etc. Information about the child may include such items as: age, sex, race, religion, interests, hobbies, family situation, etc.
The client or volunteer agrees not to disclose personal information about the respective parties to anyone outside of the agency.

Please check the box to acknowledge the policy above:

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.

Volunteer Agreement

My consent below indicates that I have answered all questions on this page truthfully. I am aware that according to Big Brothers Big Sisters Services, Inc. my status as a volunteer makes me a mandated reporter of any suspicion of child abuse and/or neglect.

My consent at the bottom of this page also indicates that I promise to abide by the Code of Conduct for volunteers of Big Brothers Big Sisters Services, Inc.:

To avoid the use of tobacco products when in the company of my Little.
To refrain from ingesting any alcoholic beverage prior to or during my visits with my Little.
To never use illegal drugs at any time.
To use no form of physical or verbal abuse (including corporal punishment) against my Little.
To have no form of sexual contact between myself and my Little or their family members (includes nudity).

Are you associated with any organization that promotes or approves of sexual contact between adult and children?

Are you taking any medications that would interfere with your ability to transport or interact with a child?

Are you undergoing any type of mental health therapy (medication and/or counseling) that would cause any difficulties in your relationship with a child?

Are you able to fulfill a commitment to meet with a child an average of 4 hours (Site-based) or 9 hours (Community-based) a month for a minimum of 12 months? (This commitment will begin at the time the match is made).

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.I DO NOT consent, should I be matched, to having contact with my Little through Big Brothers Big Sisters' digital platform.

Cancellation and Missed Appointment Policy

The agency reserves a certain amount of time for each appointment to ensure that we are conducting high-quality interviews and ensuring program fit. A scheduled interview should be treated in the same manner as any other professional appointment. The agency asks that if you need to cancel or reschedule an appointment, you do so by notifying (via email or phone) the interviewer at least 24 hours in advance of the scheduled interview time. If you do not show up at the originally scheduled time, please understand that your enrollment may be delayed as we have a queue of applicants that will take priority

Acknowledgement required:

I agree to notify my interviewer at least 24 hours in advance if I need to postpone or cancel my appointment.

Rescheduling Appointment Policy

Due to limited staff time, rescheduled appointments or no call/no show applicants may experience delays in the enrollment process. Each applicant (family or volunteer) may have two interview reschedules. If the applicant is unable to attend the third scheduled appointment, the application will close. In this case, volunteers will be eligible to reapply in six months if they have more availability. Families will be eligible to reapply in six months or during the next child enrollment period

Acknowledgement required:

I understand that may application will close after two attempts to reschedule an interview.

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