VOLUNTEER APPLICATION

1176 Robert T. Longway Blvd, Flint, MI 48503 Phone: (810) 235-0617 Fax: (810) 235-0689

Legal Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Address*

Home Address

Street Address Line 2

CityState

Zip

Email

example@example.com

Home Phone

Work Phone

Cell Phone*

Employer*

Address

Street Address Line 2

CityState

Zip

County

Race*

Gender Identity*

Marital Status

Highest Level of Education

Occupation

Work Hours

How Long Employed

If a student list high school or college

Expected Graduation date

Date

Fraternity/Sorority Affiliation

YesNo

If yes which one

Major

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. Copies of driver's license and proof of auto insurance are required. Do you have a driver'sIf yes, state of issue and #: Expiration date: license?

Do you have a driver's license?*

YesNo

If yes state of issue and

Expiration date

Date

Do you have auto insurance?*

YesNo

If yes Company

Policy#

Attach Proof of Auto Insurance

Browse Files

List household members, relationships, and ages Names Ages Relationship

List previous addresses

State

Zip Code

Years at address (i.e., 1999-2000)

Referred by:*

SelfOther

If other please list who referred you

Would you be interested in mentoring a child with a parent who has been incarcerated? (Amachi Program-volunteer must be age 18 or older)*

YesNo

If applicable please list place of worship

Have you ever applied to be, or have been, a Big Brother or Big Sister?*

YesNo

Where

When

BBBS Agency's Phone

Please type or print information requested for three references: 1) your current or past EMPLOYER (or TEACHER) who has known you for at least 1 year, if neither apply-a friend; 2) a CO-WORKER, friend or neighbor who has known you for at least 2 years; and3) a SPOUSE (or CLOSE FAMILY MEMBER) or a second friend who has known you for at least 3 years. DAYTIME PHONE NUMBERS, PLEASE! If a High School student, adult references preferred.

1. Employer/Co-worker (school if a student, if neither applies, a Supervisor/Co-worker's Name (teacher/counselor- if a student or friend): friend):

1 Employer/Coworker school (if a student if neither applies, a friend)*

Supervisor/Coworker's Name (teacher/counselor, if a student or friend)

Daytime Phone#*

Email

example@example.com

Address

Street Address Line 2

CityState

Zip

Fax

2 Friend or Neighbor*

Daytime Phone #*

Email

example@example.com

Address

Street Address Line 2

CityState

Zip

Fax

3. Spouse (Spousal Equivalent)/Close Family Member/Friend*

Daytime Phone #*

Email

example@example.com

Address

Street Address Line 2

CityState

Zip

Fax

List any other youth organization you have worked for or been involved with as a volunteer in the past 5 years: (List Dates, Name of Organization, Contact Person, and Phone Number

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

YesNo

Where and When

Have you or anyone in your household ever been substantiated for child abuse and/or neglect by the Department of Human Services?*

YesNo

If yes explain

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) Big Brothers Big Sisters of Flint and Genesee County (BBBSFGC) agency is not obligated to match me with a youth; 4) Big Brothers Big Sisters of Flint and Genesee County does not discriminate against volunteers or employees on the basis of race, religion, national origin, color, gender, marital status, sexual orientation, gender identity, veteran status, or disability; 5) The information I provided may be used to conduct a background check, to include driving records check, criminal background check, and other records where required by local, state, or federal law for volunteers working with youth; 6)Other Big Brothers Big Sisters agencies or youth organizations where I have worked or volunteered may be contacted as references; 7)As part of the enrollment processes, I will be asked to provide additional personal information prior to any recommendations for assignment; 8) In the event of the agency's determination of my ineligibility, reasons for non-acceptance will not be disclosed, in accordance with agency policy; 9) I have read and agree to the commitment of the program which is a minimum of 12 months, meeting with my Little approximately 3-4 times per month for approximately 2-4 hours each outing for Community-Based Mentoring and approximately 30-90 minutes for Site-Based Mentoring. 10)BBBSFGC will keep your information confidential except in the cases of cooperating with law enforcement officials; 11) BBBS of Flint and Genesee County does not discriminate against children and families on the basis of race, religion, national origin, color, gender, marital status, sexual orientation, gender identity, veteran status, disability, or legal status; 12) I give my permission for BBBSFGC and Big Brothers Big Sisters of America and their funders to utilize any photos, audio tapes, video images, or other images/recordings for promotional and other purposes.

Volunteer Signature*

Date

If a High School student, a parent/guardian must complete the following: As parent/guardian, I give permission for the above applicant to volunteer as a mentor to a child. I feel he/she is capable of maintaining the commitment to the program. I understand the above information provided may be substantiated by Big Brothers Big Sisters of Flint and Genesee County to include the volunteer's employment record, physical and mental health, character references, records of law enforcement agencies or courts of law and give my permission to do SO. I give my permission for Big Brothers Big Sisters of Flint and Genesee County and Big Brothers Big Sisters of America and their funders to utilize any photos, audio tapes, video images, or other images/recordings for promotional and other purposes.

Parent Signature

Date

VOLUNTEER APPLICATION

REFERENCES