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 CONSENT TO AND UNDERSTAND THAT:

1) The references and youth serving-organization I listed may be contacted by mail, telephone, email, or in-person;

2) The information I provided may be used to conduct a background check, to include a search of public domain records, driving records check, juvenile and adult criminal history check (see attached authorization), military records, and other records where required by local, state, or federal law for volunteers working with youth;

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

4) The BBBS agency is not obligated to match me with a youth and may deny my application or close my match at any time, and to protect all participants’ confidentiality, BBBS is not required to disclose reasons for doing so;

5) Big Brothers Big Sisters of Flint and Genesee County does not discriminate against youth, families, volunteers or employees on the basis of race, religion, national origin, color, gender, marital status, sexual orientation, gender identity, veteran status, or disability;

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

7) As part of the enrollment process, I will be required to provide additional personal information, including completion of an in-person or virtual interview;

8) I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law.

a. I understand that detailed accounts of child abuse or neglect, past or present, will be reported to proper authorities;

b. I understand that certain relevant information about me will be discussed with the parent/guardian of a child who is a prospective match (this might include demographic information, information relevant to parent/child preferences, and any information relevant to a child’s safety or well-being);

9) It is my responsibility to update the agency if any of the information I provide on this application, in my interview, or any other information provided during the enrollment process changes (i.e. address, phone number, auto-insurance, new criminal charges).

10) I agree to complete questionnaires throughout my time in the program to evaluate and improve program services;

11) I agree to timely communication and follow-up with all agency staff as required by the agency.

12) If I am accepted and matched with a youth in Big Brothers Big Sisters, I will read and adhere to the Volunteer Roles and Responsibilities and Match Rules at all times throughout my involvement with the program.

13) 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.

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION

I understand that this is an application for a volunteer opportunity and is not a promise or commitment by Big Brothers Big Sisters.

In consideration of being accepted as a volunteer, I agree to release and forever discharge Big Brothers Big Sisters of Flint and Genesee County, together with its employees, agents, members, officers, directors, volunteers, and all other persons acting on its behalf, including successors in interest, heirs, attorneys, representatives, and all persons acting by, through, under, or in concert with them, from any and all known and unknown charges, complaints, claims, grievances, liabilities, obligations, controversies, damages, actions, causes of action, suits, rights, demands, costs, losses, debts, penalties, fees, attorneys’ fees and costs, and punitive damages of any kind or nature whatsoever, whether known or unknown, that may arise out of or relate to my participation in the Big Brothers Big Sisters program and its activities.

I intend and understand that this release and discharge shall be interpreted and enforced so as to provide the broadest release and discharge permitted under applicable law.

I further agree that I will not bring any claim or legal action against Big Brothers Big Sisters of Flint and Genesee County for any injury, loss, or damage I may sustain as a result of my participation as a volunteer, except to the extent caused by the sole gross negligence or willful misconduct of the agency, if such limitation is required by law.

I agree to indemnify, defend, and hold harmless Big Brothers Big Sisters of Flint and Genesee County, and its officers, directors, employees, agents, members, and representatives, from and against any and all claims, demands, actions, liabilities, damages, losses, judgments, settlements, costs, and expenses, including reasonable attorneys’ fees and costs, arising out of or related to my acts, omissions, or conduct as a volunteer, including but not limited to any breach of this application or violation of agency policies or procedures, except to the extent caused by the sole gross negligence or willful misconduct of the agency, if such limitation is required by law.

At any time while involved with the Big Brothers Big Sisters program, I agree to immediately inform my Big Brothers Big Sisters contact person of any and all infractions, violations, charges, and convictions related to any civil, domestic, or criminal matters. I understand that BBBS staff needs to be fully informed to provide the best guidance or support possible.

Volunteer Printed Name

Volunteer Signature*

Date

Parent/Guardian Printed Name:

Parent/Guardian Signature

Date

VOLUNTEER APPLICATION

REFERENCES