Mentor Application 

Big Brothers Big Sisters of Northwestern Wisconsin
Hidden Fields





Applicant Information




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Demographic Information
Demographic information is collected to honor parent preferences and allows us to make matches based on shared life experiences. We are an inclusive organization and celebrate diversity!







Emergency Contact Information


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Prior Youth Experience








Mentor Application - Policies

Background Checks

I authorize Big Brothers Big Sisters of Northwestern Wisconsin ("BBBSNW"), its staff and its agents, to investigate my background, health, character and personal history in any manner it sees fit, and, I authorize all persons, companies, schools, law enforcement, and other agencies to release to BBBSNW all information concerning such subjects and otherwise concerning my suitability to become a volunteer. I understand that this may include, but is not limited to, a criminal background check through National, State, and local law enforcement and a driving record check. I also understand this information will be used to determine my eligibility to be a Big Brother/Big Sister. I understand that if I am accepted to be a volunteer, BBBSNW will conduct ongoing criminal background and driving record checks periodically while I remain a volunteer.


Release of Liability
I, for myself, my heirs, executors and administrators, hereby release and forever discharge BBBSNW, its officers, directors, employees and agents, and all other personnel, companies, schools, organizations, law enforcement and other agencies and their officers, directors, employees and agents from any and all causes of action, suits, damages, liabilities, costs, debts, sums of money, claims and demands of any sort whatsoever, and any and all related attorney's fees, court costs and other expenses, in each case that result from or relate to my relationship with any youth I volunteer to mentor or that otherwise result from or relate to my services as a volunteer or my application to become a volunteer.

Insurance Coverage & Accident Policy
I understand that as a BBBSNW volunteer I am required to submit a valid copy of my driver's license and evidence of my automobile insurance to BBBSNW prior to matching. I understand that I am required to maintain a valid driver's license and automobile insurance throughout my participation in the Big Brothers Big Sisters program, and that I will be responsible for promptly notifying BBBSNW of any change in my driver's license or automobile insurance, as well as any arrest or conviction for a moving violation. I release BBBSNW and any agents of BBBSNW, companies, schools, organizations, law enforcement and other agencies and their officers, directors, employees and agents from any liability that may result as a result of any automobile accidents that may occur while I am volunteering with BBBSNW.

Program Evaluation
I give permission for any staff member of BBBSNW to review all information contained in my volunteer file for the purpose of matching, evaluation, program audit and staff training. I also give permission to the staff and agents of Big Brothers Big Sisters of America to review my volunteer file in connection with their periodic audit for purposes of evaluation.

Media Release

Sharing stories and celebrating your success is an important part of our mission!


Confidentiality & Reporting Neglect or Abuse

I understand that all information obtained from me or about me will be held in confidence by BBBSNW. I will only have access to this digital application. All other information concerning me, including but not limited to information derived from my references, the investigative process, interviews or otherwise, will be the sole property of BBBSNW. BBBSNW will not release to outside sources, unless required by law, information from my volunteer file other than verification that I am a volunteer, without my prior written consent. BBBSNW does not share files with volunteers or families.


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.  I understand that this confidentiality policy does not include Big Brothers Big Sisters agency staff who I might speak with regarding any circumstances of my match. Information that I 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.

 

Reporting Abuse and Neglect: I will contact my Match Support Specialist immediately if my Little shares any information regarding abuse or neglect or if I suspect any abuse or neglect.

 

I have read the above statement and understand Big Brothers Big Sisters of Northwestern Wisconsin's policy regarding confidentiality of my Little’s personal life.  I agree that I will fully adhere to the terms of the policy as a condition of my involvement 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 and thereafter.


Firearm Agreement


I will inform agency staff if I or someone I live with acquires a firearm (or an additional firearm) throughout any point of my involvement with the agency, and I agree to abide by the firearm storage agreement. 

 

As a volunteer Big Brother/Big Sister, I agree to keep all firearms/weapons that may be in my home inaccessible to my Little.  I will do this by assuring that the following precautions are taken:

  • All firearms/weapons in my household will be unloaded, locked-up, and inaccessible to my Little.

  • All firearms in my household are registered when legally required.

  • Any bullets or ammunition in my household will be locked-up separately from the firearms/weapons and will be inaccessible to my Little.

  • My Little will have no knowledge of firearms/weapons being stored in my home.

  • I will not carry a weapon on me during any match activity with my Little, even if I have a concealed carry permit.

  • If I am a site-based Big Brother/Big Sister, I will not bring a weapon with me when I visit my Little at the site.


    I realize that if there is a firearm/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 understand that this agreement may be discussed with the Little’s parent or guardian in the match proposal call, and will be monitored by BBBS staff in follow-up calls.


Activities in the Volunteer's Home

Visits to the volunteer’s home are strictly prohibited for the first 4 visits of a Community-based match.  Parent/Guardians are not permitted to allow home visits within this timeframe.  After 4 match meetings, volunteers must have the consent of the Parent/Guardian in order for home visits to occur on outings and should consult with BBBS program staff prior to these outings. Any violation of this policy could result in immediate closure of the match.

 

Site-based program – activities outside the designated location (school or workplace) are prohibited including visits to the mentor’s home.


Overnight Activities

Overnight activities are not allowed within the first year of a Community Based Match, and never allowed in a School/Site Based match. Activities requiring an overnight stay after the one-year period, are not encouraged by Big Brothers Big Sisters of Northwestern Wisconsin (BBBSNW), but may be granted under special circumstances. The activity must be approved in advance by a Big Brothers Big Sisters Professional Staff member as well as the Program Director.Overnight activities should be limited and occur only occasionally and ALL the following conditions must be met: 

 

·      The match must be a community-based match for at least one year; AND 

·      The overnight activity must provide a benefit to the child that cannot be accomplished without an overnight stay; AND 

·      The volunteer must discuss the proposed overnight activity with the parent before bringing it up to the child; AND

·      The volunteer must also ask the child if he/she wishes to participate and be sensitive to any hesitation on the child’s part; AND 

·      The volunteer must also inform BBBSNW of the proposed overnight activity prior to event; AND 

·      The volunteer must obtain permission from the child’s parent or legal guardian; AND 

·      The volunteer must provide separate, private areas for the child to shower or bathe, change clothes and sleep; AND 

·      All parties (the Bigs, Little, and parent/guardian) must approve of the overnight activity. *BBBSNW reserves the right to reject the activity request; AND 

·      The volunteer must complete and return the “Overnight Activity Information Sheet” and must have the parent/guardian’s signature; AND 

·      The “Overnight Activity Information Sheet” must be submitted to BBBSNW at least one week prior to the activity; AND

·      The match has not had more than 2 overnights in one calendar year. 

 

School-Based matches shall never have overnight visits. Failure to comply with this overnight policy may result in the closing of the match. 


Mentor Training
I acknowledge that I will attend a Big Brothers Big Sisters group training prior to being matched.

Notification of Life Changes
I understand that as a BBBSNW volunteer I am required to notify BBBSNW promptly of any changes in the information I have provided during the application process that may alter my ability to serve in the capacity for which I have applied, including any changes in medical, psychological, or arrest history. I understand that such information may be released to the parent or guardian of a child with whom I am matched, and I consent to the release of such information.

Volunteer Agreement

Big Brothers Big Sisters of Northwestern Wisconsin is a nonprofit organization whose mission is provide children facing adversity with strong and enduring, professionally supported 1-to-1 relationships that change their lives for the better, forever.  While the program is an interfaith and inter-racial one, the desires of the child’s parent or guardian are respected in the selection of the appropriate adult for each child.

 

 

In determining whether an applicant may be considered for a match and what information shall be communicated to each party involved, consideration must be given to those past and present factors of the health, personality, and behavior of each individual and/or family constellation which professional agency personnel deem, under the circumstances, may have a significant effect upon the relationship.  Relevant information shall be provided; however, the name or names of the parties described shall be held confidential before a match is made.  Any party has the right to refuse to enter into the match based upon the information so communicated.

 

The information provided to the parent/guardian of a potential match assignment shall include the following:  age, race, religion, sexual orientation, marital status and/or current living situation, a summary of the volunteer’s family background, current home life, a description of the home setting, whether weapons are owned, a summary of the volunteer’s employment history, hobbies and interests, and an assessment of the volunteer’s strengths and limitations as they relate to program participation. Parents/Guardians are encouraged to visit a volunteer’s home prior to accepting a potential volunteer applicant.  Ultimately, it is the parent and child’s decision to accept a potential volunteer for a match with a child.

 

 

I acknowledge and agree that (1) I am not obligated, if called upon, to perform the volunteer services herein applied for and the agency is not obligated to assign me a Little Brother/Little Sister, and (2) as a part of the agency’s selection process, police records and employment will be checked by professional agency personnel.  I certify by my signature below that all of the information given in this application is true and accurate to the best of my knowledge, and I further authorize Big Brothers Big Sisters of Northwestern Wisconsin to use proper channels to verify the same.   Any misrepresentations, falsifications, or material omissions in any of this information or data may result in the agency’s exclusion of the applicant/volunteer from further consideration for a match, or if the applicant/volunteer has already been matched, termination of the match.


Acceptance Policy
I understand that BBBSNW reserves the right to reject a candidate for any reason that BBBSNW, in its sole judgment, determines will or may affect either the best interests of a Little Brother/Little Sister or BBBSNW. Furthermore, BBBSNW reserves the right to withhold the reasons for such refusal.

Mentor References

We require three references to become a mentor in addition to references from youth serving organizations you have been involved with in the last 5 years. 

I consent to and understand that:

  1. The references and youth serving-organization I listed may be contacted by mail, telephone, email, or in-person

  2. 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;

  3. I am in no way obligated to perform any volunteer services

  4. The Big Brothers Big Sisters 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, Big Brothers Big Sisters is not required to disclose reasons for doing so

  5. Other Big Brothers Big Sisters agencies and youth organizations where I have worked or volunteered may be contacted as references

  6. As part of the enrollment processes, I will be required to provide additional personal information, including completion of an in-person interview

  7. I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted below.

  8. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities

  9. 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)

  10. It is my responsibility to update the agency if any of the information provided 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.)

  11. I agree to timely communication and follow-up with all agency staff. 

  12. I understand that records are not available for review by clients, parents/guardians, and/or volunteers.

Significant Other Reference - if no Significant Other please list another Family Member






# years
Personal Reference






# years
Personal Reference






# years

Full Name

Mentor Consent

Big Brothers Big Sisters of Northwestern Wisconsin is a nonprofit organization whose mission is to create and support one-to-one mentoring relationships that ignite the power and promise of youth. While the program is an interfaith and inter-racial one, the desires of the child’s parent or guardian are respected in the selection of the appropriate adult for each child.


In determining whether an applicant may be considered for a match and what information shall be communicated to each party involved, consideration must be given to those past and present factors of the health, personality, and behavior of each individual and/or family constellation which professional agency personnel deem, under the circumstances, may have a significant effect upon the relationship. Relevant information shall be provided; however, the name or names of the parties described shall be held confidential before a match is made. Any party has the right to refuse to enter into the match based upon the information so communicated.


The information provided to the parent/guardian of a potential match assignment shall include the following: age, race, religion, sexual orientation, marital status and/or current living situation, a summary of the volunteer’s family background, current home life, a description of the home setting, a summary of the volunteer’s employment history, hobbies and interests, and an assessment of the volunteer’s strengths and limitations as they relate to program participation. Parents/Guardians are encouraged to visit a volunteer’s home prior to accepting a potential volunteer applicant. Ultimately, it is the parent and child’s decision to accept a potential volunteer for a match with a child.


I acknowledge and agree that (1) I am not obligated, if called upon, to perform the volunteer services herein applied for and the agency is not obligated to assign me a Little Brother/Little Sister, and (2) as a part of the agency’s selection process, police records and employment will be checked by professional agency personnel. I certify by my signature below that all of the information given in this application is true and accurate to the best of my knowledge, and I further authorize Big Brothers Big Sisters of Northwestern Wisconsin to use proper channels to verify the same. Any misrepresentations, falsifications, or material omissions in any of this information or data may result in the agency’s exclusion of the applicant/volunteer from further consideration for a match, or if the applicant/volunteer has already been matched, termination of the match.


I give my permission for my picture to be taken for the promotion of the Big Brothers Big Sisters program and utilized for public relations purposes. 



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