Film and Television Career Mentorship Program

Big Brother/Sister Volunteer Application

Roybal is recruiting volunteers for our brand new Film and Television Career Mentorship Program – powered by Big Brothers Big Sisters of Greater Los Angeles.

To learn more, please click here!

Please note that all information received is confidential and becomes the property of Big Brothers Big Sisters of Greater Los Angeles. Big Brothers Big Sisters does not discriminate on the basis of race, ethnicity, sexual orientation, religion, or physical ability.

Please complete the following application by Friday, July 21st.

Hidden Fields

Contact ID 18 Character

Enrollment ID 18 Character

Contact Owner ID

Basic Information

First Name

Middle Name

Last Name

Maiden/Alias

Date of Birth

Age

Social Security Number

Gender

How do you identify?

Marital Status

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

Nationality

To select multiple, hold CTRL/CMD and click.

Contact Information

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

Mobile Phone

Work Phone

Best Time to Call

Primary Email

Employer Information

Employment Status

Employer's Name

Occupation

Employment Length (Months)

Employment Length (Years)

Employer Address Line 1

Employer Address Line 2

City

State

Zip Code

Driver's License Information

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

Emergency Contact Information

Name

Phone

Relationship

Additional Information

Do you speak Spanish?

How much Spanish would you say you speak or understand?

Any other languages you speak:

Level of Education

Years Completed/Graduated

Referral Source

Please specify/name

Pre-interview Questionnaire and Interests

Why do you want to become a Big?

I am comfortable providing mentorship for students in the following pathway:

Art Direction	Costume Design
Hair and Makeup	Editing
Visual Effects	Animation
Camera	Lighting
Sound

Choose only one

Pre-interview Questionnaire

Prior to your in-person interview, we would like you to 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 programs.

1. Have you ever been convicted of a felony or misdemeanor?

YesNo

Please explain:

2. 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, getting married, etc.)

YesNo

Please explain:

3. Have you had any driving citations and/or moving violations in the past 3 years?

YesNo

Please explain:

4. Do you have fears or concerns about becoming a Big?

YesNo

Please explain:

5. Are you experiencing any physical and mental health problems?

YesNo

Please explain:

6. What type of a young person would you prefer to have as a Little and why?

7. What are your 3 greatest strengths?

Big Interests

Please note that we encourage Bigs to choose low cost or no cost activities on their outings with their Little.

1. What are your 3 favorite activities?

2. Do you have pet(s)?

YesNo

What kind?

3. What do you like to read?

4. What are some favorite T.V. programs?

5. Do you play a musical instrument?

YesNo

What kind?

References and Previous Youth Experience

References

Please fill in the contact information for each of your references completely, and inform them that Big Brothers Big Sisters will be contacting them shortly. Please ask them to respond within two weeks of the day of your interview.

Reference #1: Spousal/Familial

If married or living with a domestic partner, please provide them as your first reference. If not married or living with a domestic partner, please provide a family member as your first reference.

Spousal/Familial Reference ID

First Name

Last Name

Phone

Relationship to you

Years Known

Reference #2: Personal

A close friend or family member who has known you for at least 2 years and has seen you around a child.

Personal Reference 1 ID

First Name

Last Name

Phone

Relationship to you

Years Known

Minimum 2 years

Reference #3: Professional

A work or school reference who has known you for at least 1 year and has seen you around a child.

Professional Reference ID

First Name

Last Name

Phone

Relationship to you

Years Known

Minimum 1 year

Reference #4: Personal

A close friend or family member who has known you for at least 1 year and has seen you around a child.

Personal Reference 2 ID

First Name

Last Name

Phone

Relationship to you

Years Known

Minimum 1 year

Previous Youth Experience

Have you worked with "at risk" youth before?

Please provide the contact information for all organizations you have worked/volunteered for within the last 5 years.

YSO Reference ID

Organization Name

Location

Start Date

End Date

Direct Supervisor First Name

Direct Supervisor Last Name

Phone

Reason for Leaving

Authorization for Past Volunteer Experience

In order for Big Brothers Big Sisters of Greater Los Angeles to provide a service that is in the best interest of the children served by the program, information from outside resources, including previous youth experience references, must be assessed. For this reason, it is necessary for the agency to contact any organization that the potential volunteer has worked/volunteered with in the last 5 years. By signing below you understand and authorize named organization(s) or people to mutually share the requested information with Big Brothers Big Sisters of Greater Los Angeles. Furthermore, any information provided by the organization will be considered confidential and will not be shared with the applicant.

I authorize the above named organization(s) or people to mutually share the requested information with Big Brothers Big Sisters of Greater Los Angeles.

I Agree

I understand that by typing my name below, I am electronically signing this document.

I Agree

Applicant's Full Name

Today's Date

Policy on Assessment and Matching for Volunteers

Our mission is to provide children facing adversity with strong and enduring, professionally supported one-to-one relationships that change their lives for the better, forever.

Big Brothers Big Sisters provides a mentoring program designed to help children whose parent/guardian has indicated a need for having a strong role model in their lives. While the program is interfaith and interracial, the desires of the child’s parent or guardian are respected in selection of the appropriate man/woman for each child.

In determining whether an applicant may be accepted into the program, consideration will be given to personal factors of each applicant. Professional Agency personnel will determine, at their sole discretion, whether these factors may have a significant effect upon the relationship, and if revealed at a later date, could affect it adversely.

Personal interviews are conducted to establish a profile of each applicant. All information will be kept in strictest confidence. Prior to a suggested matching, a similar profile of the Little Brother/Little Sister and his/her family will be discussed with the Big Brother/Big Sister applicant.

THE UNDERSIGNED ACKNOWLEDGES AND AGREES THAT (1) IF SELECTED, THE APPLICANT IS OBLIGATED TO PERFORM THE VOLUNTEER SERVICES HEREIN APPLIED FOR (2) THE AGENCY IS NOT OBLIGATED TO ASSIGN OR ACTIVELY SEEK TO ASSIGN A LITTLE BROTHER/LITTLE SISTER TO HIM/HER; AND (3) AS A PART OF THE AGENCY’S MATCHING PROCESS, ADDITIONAL PERSONAL INFORMATION MAY BE REQUESTED.

*IN THE EVENT THE APPLICANT IS NOT ACCEPTED, THE REASONS WILL REMAIN CONFIDENTIAL AND CONNOT BE DISCUSSED WITH THE APPLICANT.

Confidentiality Policy

Access to Confidential Records

In order for Big Brothers Big Sisters of Greater Los Angeles to provide a responsible and professional service to the community, it is necessary for volunteers, children and parents/guardians to divulge personal information about themselves and their families. The agency respects the confidentiality of child and volunteer records and, with the exception of situations listed below, shares information about children and volunteers only among the staff. The right to confidentiality applies to written records, video, film, pictures and use of a child’s or volunteer’s name in agency publications.

In order to provide a service that is in the best interest of the children served by the program, information from outside sources, including confidential references, must be assessed along with information gained from the children, parents/guardians, or volunteers themselves.

All records are solely the property of Big Brothers Big Sisters of Greater Los Angeles. Records are not available for review by the children or volunteers. At the initial interview, children, parents/guardians, and volunteers are provided below with a copy of this statement on confidentiality along with the exceptions that define the limits of confidentiality. Each parent and volunteer shall sign a statement that he/she has read and understands the agency policy on confidentiality and agrees to program participation under the policy, in the form set forth.

Limits of Confidentiality

California state law mandates that suspected child abuse be reported to the Department of Children and Family Services. Child abuse means a physical injury that is inflicted by other than accidental means on a child by another person. Child abuse may result from either an act or a failure to act, as in the case of neglect. Child abuse also includes sexual abuse. All professional staff and volunteers shall always comply with current law and mandated procedures.

If an agency worker receives information indicating that an individual may be dangerous to himself or herself, or to others, necessary steps must be taken to protect the appropriate party. This may include a medical and/or psychiatric referral or a report to the local enforcement authorities.

Relevant information about a prospective volunteer and about a prospective Little and his/her family will be presented to a prospective match mate. First names only are used in this presentation. The information is shared in order for the prospective Big and/or Little and family to make the most informed choice.

Identifying information regarding children and volunteers may be used in agency publications or promotional materials unless a media consent is withheld by the child or volunteer.

Information will be released to other individuals or organizations only upon presentation of an authorized “consent to release information” form signed by the child’s parent/guardian or volunteer.

For purposes of program evaluation, audit, or accreditation, certain outside bodies such as Big Brothers Big Sisters of America may have access to child and volunteer records. Such access will be provided only on condition that these outside organizations agree to adhere to the agency policy on confidentiality. Violations of agency confidentiality policy will be reported to the supervisor of the individual involved and appropriate disciplinary action shall be imposed. Violations of the agency’s confidentiality policy may result in termination of the employment/volunteer relationship.

Members of the Board of Directors may have access to a child’s file only upon a duly authorized motion of the Board of Directors. The motion shall state who shall be authorized to review records, the specific purpose for such review and the period of time during which access shall be granted. Members shall be required to comply with the agency policies on confidentiality and may use the information only for the purposes stated by the approved action of the Board of Directors. Violations shall be reported to the Board President. A violation of the agency’s confidentiality policy by a Board Member shall constitute adequate cause for removal from office.

Information shall be provided to governmental agencies, law enforcement officials, or the courts only following a valid and enforceable subpoena, court order, or in accordance with applicable law.

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

Acknowledgment

Please read, initial, and date to certify.

Agency Policy: I attest that all of the information provided by me in the Big Brother/Big Sister application and screening process is, to the best of my knowledge, true and accurate, and that I do fully understand all the questions and statements discussed.

Initial Above

Confidentiality: I have read and understand the above information, which states the agency policy with respect to confidentiality of child and volunteer records. I agree to program participation under the conditions it sets forth.

Initial Above

Survey Consent: I give my consent to participate in all assessment and evaluation services given by Big Brothers Big Sisters of Greater Los Angeles. Assessments and evaluations can be conducted in person, over the phone, through email or mail.

Initial Above

Orientation: I have completed the application process for serving as a Big Brother or Big Sister. I was interviewed in-person by an Enrollment Matching Specialist and the Volunteer Orientation Guide was shared with me. If accepted into the program, I understand that a Match Support Specialist will be in contact with me once I am matched with a child to provide ongoing training and support. I also recognize that it is my responsibility to share any questions or concerns I may have about my match or the matching process with the staff of Big Brothers Big Sisters of Greater Los Angeles (BBBSLA).

Initial Above

I certify that I have read, understand, and agree to comply with all of the policies stated herein.

I Agree

I understand that by typing my name below, I am electronically signing this document.

I Agree

Applicant's Full Name

Today's Date

Media Consent and Release Form

I understand that Big Brothers Big Sisters of Greater Los Angeles (“BBBSLA”) is seeking to use my image, likeness, name, biographical information, personal characteristics, quotations, writings, information contained in writings, and/or audio or video recordings of me, whether made through BBBSLA or elsewhere (the “Released Material”) for or in BBBSLA publications or productions.

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 BBBSLA the right to use the Released Material as BBBSLA 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 BBBSLA.

I further grant to BBBSLA 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 BBBSLA that use the Released Materials are the property of and are owned by BBBSLA, and that I cannot authorize their use by any other party. I hereby irrevocably transfer and assign to BBBSLA 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 BBBSLA, and that BBBSLA has no liability to me for any editing or alteration of the Released Materials or for any distortion or other effects resulting from BBBSLA’s editing, alteration or use of the Released Materials. BBBSLA has no obligation to use the Released Materials or to exercise any rights given by this Consent and Release Form.

I further acknowledge that, if invited and available, I am willing and able to attend and/or speak on national or local television about my involvement with BBBSLA, including to speak about the mentoring match in which I am engaged, have engaged, or wish to engage. I understand that BBBSLA will pay for travel and travel-related expenses if I am required to travel for such an appearance.

I hereby release BBBSLA from all claims, demands or liabilities and related financial costs that I may now or hereafter have arising in connection with BBBSLA’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.

Opt InOpt Out

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.

I understand that by typing my name below, I am electronically signing this document.

Applicant's Full Name:

Today's Date

COVID-19 | Assumption of Risk, Hold Harmless and Liability Release

In connection with my participation in, and in connection with my engagement with, Big Brothers Big Sisters Of Greater Los Angeles (“Organization”) and for other good and valuable consideration, I hereby acknowledge and agree the following as part of this Assumption of Risk, Hold Harmless and Liability Release (the “Release”)

I acknowledge, understand, and am aware that portions of the Organizations activities are intended to take place in regions potentially affected by COVID-19 (also known as the Coronavirus) and other diseases, illnesses and hazards (collectively, “Affected Area”), and that I may be in proximity to and/or interacting with individuals who may be sick, who may or may not be exhibiting symptoms or who may be infected by COVID-19 or who may be otherwise contagious. I am aware that the Centers for Disease Control and Prevention (“CDC”), in addition to other local, state and federal health and government agencies have issued numerous alerts, warnings, advisories, restrictions, directives and in some cases orders regarding the transmission and potential effects of COVID-19 and I fully acknowledge and accept the risks involved in voluntarily being in the Affected Area. I hereby acknowledge and agree that I am voluntarily deciding to remain in the Affected Area and that my decision to do so is mine and mine alone, which I arrived at after careful thought and consideration, and which has not been influenced by Organization, or any representatives, employees, agents or affiliates thereof, and further, such decision is not required as a condition of my future services, activities, or involvement in connection with the Organization or otherwise. I further acknowledge that my election to remain in the Affected Area may significantly increase my risk of contracting COVID-19. By electing to remain in the Affected Area, I acknowledge and agree that I am voluntarily potentially exposing myself to various hazards, including but not limited to, illness, injury, infection, and/or death. I acknowledge and agree that it is my responsibility to take appropriate health and safety precautions. I freely and knowingly accept and assume any and all risks of being in the Affected Area as well as any risks not mentioned herein that are associated with my engagement in and in connection with the Organization.

I represent and warrant that I am in good physical health, that I do not have any of the conditions that the CDC has categorized as “high risk” in the event I contract Covid-19 (including, without limitation, preexisting, underlying or chronic health conditions or previous medical concerns or diagnosis), and that I am physically able and mentally capable of engaging in the Organization’s activities in the Affected Area. In the event I begin to exhibit symptoms of Covid-19, or I otherwise feel sick, I acknowledge and agree that I will immediately notify the Organization and discontinue my engagement hereunder. Additionally, I will immediately notify Organization if I have been exposed to, or am exposed to, someone who has tested positive for Covid-19.

To the fullest extent permitted by law, I hereby expressly release, indemnify, discharge and hold harmless Organization, and its licensees and assigns, and each of their respective parent, subsidiary, affiliated and related companies, and their respective officers, directors, employees, representatives, licensees, assigns and designees, from and against any and all liability, claims, demands and causes of action of any kind, including without limitation, claims for personal injury, disability, death, property damage and/or other loss of any sort suffered by me in connection with my engagement by Organization, or any other adverse consequences or outcomes that may result from my engaging in services in connection with the Organization and/or being in the Affected Area.

This Release shall be deemed to be entered into in the State of California and shall be governed by and interpreted in accordance with the internal laws of the State of California. If any controversy or claim arising out of or relating to this Release, or the breach of any term hereof, cannot be settled through direct discussions, the parties agree to endeavor first to settle the controversy or claim by mediation conducted in Los Angeles County, California and administered by JAMS under its Commercial Mediation Rules. If a controversy or claim is not otherwise resolved through direct discussions or mediation, it shall be resolved by arbitration conducted in Los Angeles County, California, and administered by JAMS in accordance with the commercial arbitration rules of JAMS (the "JAMS Rules"). The JAMS Rules for selection of an arbitrator shall be followed, except that the arbitrator shall be an experienced arbitrator licensed to practice law in California.

This Release is in addition to any similar assumption of risk or releases that I may have previously entered into with Organization. This Release shall in no way be deemed to limit such previous release (if any) or its applicable provisions, and I agree that the waivers, releases, assumptions of risk and indemnities in any such previous release or agreement shall additionally expressly apply to my engagement with the Organization and/or my being in the Affected Area hereunder. In the event of a conflict between the any previous release or agreement and this Release, the terms of this Release shall govern solely to the extent necessary to resolve such conflict.

I fully understand and agree that my electronic signature below constitutes an express assumption of any and all risks arising out of or in connection with rendering services in the Affected Area and I intend my signature to be a complete and unconditional release of liability to the maximum extent allowed by law. I certify that I have read, understand, and agree to comply with all of the policies stated herein.

I Agree

Applicant's Full Name:

Today's Date:

Application Acknowledgment

By signing this application, you are confirming the following:

I am at least 18 years old.
I am willing to make a minimum of a one year commitment to the program and forming a long term relationship with a child.
I have a safe driving record.
I possess a valid driver's license, current car insurance, and a car.
No illegal drug use.
I have never been convicted of a felony.
I understand that Big Brothers Big Sisters is not obligated to match me with a youth, and that at this time I am not committing to perform any volunteer services.
I affirm that all information provided by me to Big Brothers Big Sisters is true and accurate.
I understand that misrepresentation or omission of the facts called for is cause for dismissal. I further authorize the use of the information provided to conduct a DMV check, criminal background check, and other records where required by local, state, or federal law for individuals working with youth.
I understand that my eligibility and acceptance as a volunteer is at the discretion of BBBS and my file can be closed at any time. Furthermore, I understand that to preserve confidentiality the reasons for closure cannot be disclosed at any time.

I understand that by typing my name and clicking "Submit" below, I am electronically signing this document.

I Agree

Applicant's Full Name:

Today's Date: