Of Cowley County
1321 E. 7th, Winfield, KS 67156 /

BIG BROTHERS BIG SISTERS APPLICATION

/
Phone: 620-221-7766
Fax: 620-221-2977
E-mail:

Application available on line at

PERSONAL INFORMATION / PLEASE PRINT

Please indicate which program you are applying for: (check as many as apply)Date:______

Community-based Programs ___Big Brother ___Big Sister ___Couple Match ___Family Match

Site-based Programs ___Bigs in Schools

Special Interests ___Malisa’s Hope (faith-based) ___Pass-It-On (Outdoor Mentors) ___ Cops for Kids

___Mi Amigo (Hispanic focus) ___HighSchool ____Amachi

11/5/18

Name______
Legal First Name Nick Name (if any) Last / Occupation______
Maiden name (if applicable)______/ Employer or School______
Home phone______Cell phone______/ Squad & Rank (if app)______
Home address ______/ Business phone______
City ______Zip ______/ Permanent address: ______
E-mail address(es) ______/ May we call you at work? ______Best times______
How long at your current address?______/ City and State of Birth ______
Driver's License # ______State______
Tag Number______Auto Insurance______/ Race______, Gender: Male____ Female____
Birth date ______/ Marital Status: ( ) Single ( ) Married ( ) Separated
( ) Divorced ( ) Widowed
Social Security #:______/ Spouse’s name (if applicable) ______
Education completed:______
Emergency contact?______/ Church or Congregation______
Address ______Phone______/ Hunter’s Education Card #(Outdoor Mentors Only)______
Have you applied to be a Big Brother or Sister anywhere before? If so list agency, address & date:
______
Please list names and numbers of anyone you know well, who is associated with Big Brothers Big Sisters:
______
Have you formally worked with children within the last three years? If so list organization, contact name and phone number:
  1. ______
  2. ______
  3. ______
  4. ______

REFERENCES REQUIRED / PLEASE PRINT

Community-based Big Brother/Sister/Couple or Family Volunteers

1 Employer

4 Personal References

*High School Volunteer: please provide two school staff

*Couples or Family volunteers at least 1 from someone who knows you as a couple & list as reference #4

Site-based Volunteers

1 Employer

3 Personal References

*High School Volunteer: please provide two school staff

Personal references should be individuals who know you well (preferably at least two years). Couple References are individuals who know both members of the couple.

Complete address needed to mail references. Please, do not list relatives!

Employer Reference / (If not employed, please provide one additional personal reference.)

______Home phone: ______

Supervisor’s nameMailing AddressCityStateZip Work phone:______

______Cellphone:______Company-Business Name Email: ______

Personal References

______Home phone: ______

Reference #1AddressCityStateZip Work phone: ______

Relationship:______Email: ______

Cell phone:______

______Home phone: ______

Reference #2AddressCityStateZip Work phone: ______

Relationship:______Email: ______

Cell phone:______

______Home phone: ______

Reference #3 AddressCityStateZip Work phone: ______

Relationship:______Email: ______

Cell phone:______

______Home phone: ______

Reference # 4AddressCityStateZip Work phone: ______

Relationship:______Email: ______

Cell phone:______

I understand that a Kansas Bureau of Investigation and/or Police Department and/or other criminal background checks, a child abuse registry check, a motor vehicle check, court diversion check, and sex offender check will be made of my background and that all information about me will be kept confidential by Kansas Big Brothers Big Sisters. My consent to which is hereby given, which consent shall be a continuing consent to periodic record checks for as long as I am matched to a Little Brother or Sister.

I understand that my service as a Kansas Big Brother or Big Sister (KSBBBS) is voluntary and consensual and that I serve at my own risk. I understand KSBBBS Inc. assumes no liability for my well being and does not provide insurance coverage for injuries I sustain during my service as a Big Brother or Big Sister. I understand that I am responsible for providing my own insurance, including but not limited to personal liability and automobile insurance and health and accident insurance.

Signature XDate

11/5/18