Big Brothers Big Sisters Volunteer Application

Big Brothers Big Sisters Volunteer Application
Full Name

First NameMiddle NameLast Name
Maiden Name / Alias

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Social Security #
Gender
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation
E-mail
Home Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Fax #

Area CodePhone Number
Can we contact you at work?
Work Hours
How long employed
Possession of a driver’s license is not a requirement to participate in any of our programs, but is required if you will be transporting a youth in any vehicle you are operating.
Do you have a drivers license?
If yes, State of issue and #
Expiration Date

MonthDayYear
Have you ever applied before to be a Big Brother or Big Sister?
Where and When
REFERENCES
Please type or print information requested for three references: (1) your current/past employer or professor who has known you for at least 1 year; (2) a co-worker or friend who has known you for at least 2 years; and (3) a close family member (i.e. parent/domestic partner) or a second friend who has known you for at least 3 years.
Reference #1
Employers Name (or school if student)
Supervisor's Name (or teacher if a student)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Day Phone #

Area CodePhone Number
Fax #

Area CodePhone Number
E-mail
Reference #2
Co-worker or friend
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Day Phone #

Area CodePhone Number
Fax #

Area CodePhone Number
E-mail
Reference #3
Close family member/Friend
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
E-mail
The undersigned acknowledges and agrees that (1) he/she is not obligated if called upon, to perform the volunteer services herein applied for and that the Agency is not obligated to assign or to actively seek to assign him/her a Little Brother/Little Sister; and that (2) as part of the Agency’s matching process, additional personal information will be elicited from the applicant by professional Agency personnel (3) the agency will access Criminal Offender Record Information (CORI).
Date

MonthDayYear
Signed
CORI Request Form
Big Brothers Big Sisters of Hampden County has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee for the position of Big Brother/Big Sister, I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge.

XBBSHC
FE016

Applicant/Employee Information
Full Name

First NameMiddle NameLast Name
Maiden Name or Alias (if applicable)

First NameMiddle NameLast Name
Place of Birth
Date of Birth

MonthDayYear
Social Security #
Mother's Maiden Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Former Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sex
Height - ft. & in.
Weight
Eye Color
State Driver's License Number
THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHED IDENTIFICATION
Requested by (signature of CORI authorized employee
Type letters in the box
Should be Empty:

Big Brothers Big Sisters Volunteer Application

REFERENCES

CORI Request Form