Big Brothers Big Sisters of Rush County
HIGH SCHOOL SPORTS BUDDY PROGRAM-BIG’S ENROLLMENT FORM
Name: Male Female Grade in School
Date of Birth: Name of School:
SS #: E-mail Address:
Current Address (including city, state and zip code):
Home Phone : Cell Phone/Other# :
Have you previously applied (or served) as a Big Brother or Big Sister? Yes No
If yes, where and when?
Do you speak any languages other than English? Yes NoIf yes, please list:
Please describe any physical, emotional or medical challenges/conditions you may have that might affect your participation in this program.
Have you ever been arrested, charged with or convicted of a crime? Yes NoIf yes, please explain:
References:
Please printcontact information for three persons who know you well:
1.A current or past teacher who has known you for at least 1 year:
Teacher’s Name:
Name of school where teacher is employed:
Address, City, State, Zip:
Daytime Phone Number: e-mail:
2.A parent/guardian:
Parent/Guardian’s Name: ______
Address, City, State, Zip:
Daytime Phone Number: e-mail:
3.An adult, 18 or older, who has known you for at least 2 years, but is not a member of your immediate family:
Adult’s Name: Relationship:
Address, City, State, Zip:
Daytime Phone Number: e-mail:
For Statistical Purposes Only:
Ethnicity: African-American Asian Caucasian Hispanic Other
How did you learn about this program? Friend Website Special Event TV Radio
PartnerSchool Other
(please complete reverse side)
I understand that:
~I will be expected to complete all group and online training as directed by BBBS staff.
~The information I have provided may be used to conduct a background check, which may include a driving records check, criminal background check, and check of other records as required by local, state, or federal law for volunteers working with youth;
~I will attend monthly events and be matched with a “Little” for the event.
~I am prohibited from exchanging phone numbers, addresses or email addresses with the Little’sI meet while volunteering.
~I will help at BBBS fundraisers when needed.
~By signing below I state that I understand and agree to follow all agency guidelines presented to me during the course of my volunteer service with this agency. I understand that violation of agency guidelines may result in my dismissal from the program.
~I further agree to be drug and alcohol free at all times during my volunteer service.
I hold all the above information to be true and correct.
Signature of High School VolunteerDate
THIS SECTION MUST BE COMPLETED BY THE PARENT/GUARDIAN OF
THE ABOVE NAMED HIGH SCHOOL STUDENT:
Dear Parent/Guardian:
By completing the permission slip below, you are authorizing BBBS of Rush County to match your son or daughter with a elementary school-aged Little Brother or Little Sister who he/she will “mentor” at BBBS sponsored monthly sports events. All students mentoring will be done in a supervised group setting. These groups will be supervised by professional staff, employed by Big Brothers Big Sisters (BBBS) of Rush County. There will be no contact between your son or daughter and the child(ren) they are mentoring outside of the group setting.
Do you know of any reason why serving as a Big Brother or Big Sister with our agency may not be the right volunteer experience for your son or daughter? Yes No If yes, please explain:
MEDIA RELEASE (optional)
I hereby authorize BBBS of Rush County to permit pictures to be taken of my child (named above) for use in newspapers, on television stations, or by any other media form for public relations purposes for BBBS of Rush County.
Yes No (Parent Initials)
I give my permission for my son or daughter (named above) to participate in this mentoring program. I also authorize the sharing of information and records between the above named school and BBBS of Rush County in order to best serve the needs of my child. I feel that this is a good opportunity for my son/daughter and I fully support and recommend his/her involvement in this program.
Signature of Parent/GuardianDate
Printed Name(s) of Parent/Guardian:
Parent/Guardian Workplace:
Workplace Phone : May we call you at work? Yes No
Parent/Guardian Email: Cell Phone: