First Name: Last Name: Date of Birth:

Address: City: County:

State: Zip: Email:

□Home Phone #: ______□Work Phone #: ______□Cell Phone #: ______

*Please check the phone you would prefer us to use

Social Security #: Gender: Marital Status: _____

Ethnicity/Race:

□ American Indian or Alaska Native □ Asian □ Black □ Hispanic □ Multi-Race (Asian/White) □ Multi-Race (Black/Asian) □ Multi-Race (Black/Hispanic) □ Multi-Race (Black/White) □ Multi-Race (Hispanic/Asian) □ Multi-Race (Hispanic/White) □ Multi-Race (none of above) □ Native Hawaiian or other Pacific Islander □ White □ Some Other Race

Employer: Address:

City: ______State: Zip: Occupation/Job:

Can we contact you at work? ______Work Hours: From: ______to: ____ Length of Employment: _____

Best way to communicate (please circle): Text Message Email Work # Cell # Home #

Highest Level of Education:

Do you have a driver’s license? If yes, state of issue and #:

Expiration Date:

A valid Indiana driver’s license is required to participate in the community based program.

Please indicate the program in which you prefer to mentor:

□School Based □Community Based (□Bartholomew □Brown) □ Undecided

If School Based, please indicate the school(s) in which you would like to mentor:

Bartholomew County / Brown County
□Clifty Creek Elementary School 4625 E 50 N / □Brown County Intermediate School 260 School House Ln
□Fodrea Elementary School 2775 Illinois / □Helmsburg Elementary School 5378 Helmsburg Rd
□Lincoln Elementary School 750 Fifth Street / □Sprunica Elementary School 3611 Sprunica Rd
□Mt. Healthy Elementary School 12150 S SR 58 / □Van Buren Elementary School 4045 SR 135 S
□Parkside Elementary School 1400 Parkside Drive
□Richards Elementary School 3311 Fairlawn Drive
□Rockcreek Elementary 13000 E. 200 S
□Schmitt Elementary School 2675 California Street
□Smith Elementary School 4505 Waycross Drive
□Southside Elementary School 1320 W County Rd 200 S
□Taylorsville Elementary School 9711 Walnut Street

Have you ever applied before to be (or have been) a Big Brother or Big Sister?

If yes, where and when?

Have you ever been involved before with Big Brothers Big Sisters in a capacity other than a Big? __

If yes, where and when?

What, if any, other youth organizations have you worked for or been involved with as a volunteer?

REFERENCES

Please type or print information requested for three references: 1) your current or past employer who has known you for at least 1 year; 2) a co-worker, friend or neighbor who has known you for at least 2 years; and 3) a close family member (spouse/domestic partner) or a second friend who has known you for at least 3 years.

1. Employer: / Supervisor’s Name: / # Years known:
Address: / City: / State: / Zip:
Home or cell #: / Work #: / Email:
2. □Coworker □Friend □Neighbor / # Years known:
Address: / City: / State: / Zip:
Home or cell #: / Work #: / Email:
3. □Spouse □Domestic Partner □Friend □Significant Other / # Years known:
Address: / City: / State: / Zip:
Home or cell #: / Work #: / Email:

Please list below the places in which you have resided over the past 10 years. You will be signing Releases of Information for criminal history checks at the end of this application.

YEARS / CITY / STATE / YEARS / CITY / STATE

I understand that:

1) The references I listed may be contacted by mail, telephone, or email;

2) I am in no way obligated to perform any volunteer services;

3) The information I provided may be used to conduct a background check, to include driving records check, criminal background check, a child abuse registry check and other records where required by local, state, or federal law for volunteers working with youth;

4) The BBBS agency is not obligated to match me with a youth;

5) Other BBBS agencies or youth organizations where I have worked or volunteered may be contacted as references; and,

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

______

Signature Date

BACKGROUND CHECK CONSENT FORM

First______Full Middle Name______Last______

Date of Birth______Social Security Number______

DO NOT SUBMIT THIS FORM WITHOUT YOUR SOCIAL SECURITY NUMBER

Address______

City______State______Zip______

Driver’s License Number ______State______

I understand that Big Brothers Big Sisters will make inquiry to ascertain information concerning my background and I give permission to do so. I also understand that, upon written request, information as to the nature and scope of the inquiry will be provided to me. I understand that my consent will apply throughout my volunteer activity to the extent permitted by law and periodic checks may be initiated at any time. If, while serving as a volunteer with Big Brothers Big Sisters, I am charged with a crime (felony, misdemeanor, etc.) it is my duty to report this to Big Brothers Big Sisters immediately.

______

Signature of Volunteer Date

Office Use Only

______

Report Ordered (Initials/Date) Preliminary Results

______

Results Reviewed (Initials/Date) Summary of Results and action taken

TO BE READ AND SIGNED BY AGENCY CLIENTS AND VOLUNTEERS

Big Brothers Big Sisters of Bartholomew and Brown County respects the confidentiality of client and volunteer records and, with the exception of the 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.

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

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

3.  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.

4.  Members of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors.

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

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

7.  State law mandates that suspected child abuse be reported to the appropriate authorities.

8.  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 a medical referral or report to the local law enforcement authorities.

9.  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, race, 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.

I agree to program participation under the above conditions.

______

Client’s/Volunteer’s Name

______

Date

Please return completed applications to:

For Bartholomew County: For Brown County:

Marion McCorry Wendi Gore

Big Brothers Big Sisters Big Brothers Big Sisters

405 Hope Ave. Columbus, IN 47201 PO Box 500 Nashville, IN 47448

Fax: 812-372-3226 812-988-8170