Site-Based Mentor Application
Big Brothers Big Sisters - Pittsburgh
Program Information:
Thank you for your interest in becoming a Site Based mentor with BBBS! Our Site Based Programs meet from October - May at designated times. Please indicate which program(s) you are able to volunteer at below. Once you submit the following application, a BBBS representative will contact you to provide more information on that specific program and next steps to getting involved. Thanks!
Program Options:
Schiller Middle School (North Shore): Meets every Wednesday during the students' lunch (12:21 - 1:02 or 1:49 - 2:30)
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
How do you prefer to be contacted? (Phone Call, text, e-mail, time of day, etc.)
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday:
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Month
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Day
Year
Date
Gender:
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Marital Status:
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Race:
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Nationality/Country of Origin:
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Occupation:
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How long employed?
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Work Hours:
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Highest Level of Education:
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Are you a student at this time?
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Yes
No
If yes, please name school:
Do you have current or past military experience?
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Yes
No
If yes, dates of service:
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Have you previously applied to be or served as a Big Brother or Big Sister here or anywhere else?
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Yes
No
If yes, when and where?
Have you ever been involved with Big Brothers Big Sisters in a capacity other than a Big?
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Yes
No
If yes, when and where?
Have you ever been denied acceptance or released from service as a volunteer or employee foranother Big Brothers Big Sisters program or youth-serving organization?
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Yes
No
If yes, when and where?
Are you interested in learning about additional ways to contribute to the Big Brothers Big Sisters mission?
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Yes
No
If yes, please check all interests that apply.
Becoming a donor
Helping to recruit volunteers
Volunteering at agency events for matches, Littles, waiting-list children, etc.
Volunteering at agency fundraising events
Inviting BBBS to speak at a company, church, organization , or other group of which I am a member
Reference Information
Please list information for at least three references below.
Reference 1: Your spouse or domestic partner (i.e., if you live with a significant other/girlfriend/boyfriend) OR a family member, if you do not have a spouse, partner, or significant other);
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Reference #2: Current or former employer or co-worker you have known for at least one year, or someone from your school if you are a student;
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First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Reference #3: A friend or neighbor you have known for at least two years.
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
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Youth Serving Organizations
In addition to the references above, Big Brothers Big Sisters requires references from all youth serving organizations at which you have worked or volunteered in the past 5 years. Please list additional on separate page, if needed.
Have you worked or volunteered at a youth serving organization in the past 5 years?
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Yes - please fill out the below information for each organization involved
No
Organization Name:
Direct Supervisor:
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Organization Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of Involvement/Employment:
Reason for leaving?
Organization:
Direct Supervisor:
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of Involvement/Employment:
Reason for leaving?
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I consent to and Understand that:
1) The references and youth serving-organization I listed may be contacted by mail, telephone, email, o rin-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,military records, and other records where required by local, state, or federal law for volunteers working with youth; (original copies of the clearances maybe given to the volunteer once copies are made and an employee verifies with his/her signature that he/she has seen the original); 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 anytime, and to protect all participants’ confidentiality, BBBS is not required to disclose reasons for doing so; 5) If you were a Big Brother or BigSister with another Big Brothers Big Sisters agency, Big Brothers Big Sistersof Greater Pittsburgh has the right to contact that agency and have your records released to Big Brothers Big Sisters of Greater Pittsburgh; 6) As part of the enrollment processes, I will be required to provide additional personal information,including completion of an in-person interview; 7) I understand that the information I provide in the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted below. 8) I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities; 9) 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); 10) 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, etc.). 11) My social security number will be used for background checks and to document program enrollment; 12) If I am matched with a little, my photograph may be used for the purpose of publicity efforts (video, photo and social media) by Big Brothers Big Sisters; 13) I have received a copy of the Site-Based Eligibility and Program Information Sheet;
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. I certify that all information I have provided or will provide to Big Brothers Big Sisters, including this application, is true, correct and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any informationthat would affect my application for a volunteer position. I understand that information contained on my application will be verified by Big Brothers Big Sisters. I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant or my termination as a volunteer. At anytime 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 occurrences. I understand that BBBS staff needs to be fully informed to provide the best guidance or support possible.
Name
First Name
Last Name
Signature
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Date
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Month
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Day
Year
Date
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Big Brothers Big Sisters of Greater Pittsburgh-Media Release
I hereby irrevocably grant Big Brothers Big Sisters of Greater Pittsburgh/Big Brothers Big Sisters of America the right to use images of myself, first name, and biographical information as they may desire, in all media and in all forms including, but not limited to publications, any televised photography and recordings. I hereby waive any right to inspect or approve the images and/or information that may be used now or in the future, whether that use is known or unknown to me, and I waive any rights to any compensation arising from or relating to the use of such images and/or information. By signing below, I acknowledge that I have read this release and fully understand that contents, meaning and impact of this release. Further, I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing this release, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
Name
First Name
Last Name
Signature
Date
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Month
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Year
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Submit
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