VOLUNTEER ENROLLMENT



VOLUNTEER ENROLLMENT

Big Brother Big Sister Big Couple

Community Based Virtual Mentoring University Based

|First Name: |MI: |Last Name: |Maiden Name (if applicable) |Date of Birth: |

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|Home Address: |City: |County: |State: |Zip: |

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|Email: |Home Ph #: |Work Ph #: |Cell #: |

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|Race/Ethnicity: |Social Security #: |Work Hours: |Can We Contact You At Work? |

|      |      |      |Yes No |

|Employer: |Occupation: |How Long Employed: |

|      |      |      |

|Business Address: |City: |State: |Zip: |

|      |      |      |      |

|Do you have a driver’s license? |If yes, state of issue and # |Expiration date: |Gender: |

|Yes No |      |      | |

|Auto Ins. Co. |Policy # |Marital Status: |Married How Long?: |

|      |      |      |      |

REFERENCES

References must have known you for at least 1 year.

1) Must be your current or past employer, business associate, or co-worker. If a student the school that you attend and a teacher/professor;

2) Must be a spouse/domestic partner. If neither apply the reference may be a roommate, or close family member (parent, adult child, sibling, etc.)

3) Must be a friend, neighbor, clergy person,

|1. Employer’s Name (or name of school): |Supervisor’s Name (or teacher if a student): |

|      |      |

|Address: |City: |State: |Zip: |

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|Day Phone #: |Fax #: |Email: |

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|2. Spouse/partner or roommate or family member: |

|      |

|Address: |City: |State: |Zip: |

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|Day Phone #: |Fax #: |Email: |

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|3. Friend, neighbor, or clergy person: |

|      |

|Address: |City: |State: |Zip: |

|      |      |      |      |

|Day Phone #: |Fax #: |Email: |

|      |      |      |

|Have you ever applied (or been) to be a Big Brother or Big Sister? Yes No |Where and When: |

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|What, if any, other youth organizations have you worked for or been involved with as a volunteer? |

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|List Hobbies, skills, and interests:       |

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|Please list information about all others living in your household |

|Name |Age |Relationship |

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|Please list any pets in your household |

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BACKGROUND INFORMATION

If you have been a resident of Connecticut for less than two years, please list your previous address below. This information is necessary for us to send a background check to your previous law enforcement agency. This information must be attained before you can be accepted into the program. Additional releases may need to be signed to obtain those records.

|Address: |City, State, & ZIP |

| |      |

|Name & Address law enforcement agency if known: |

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|Have you ever been arrested? No Yes If yes, please explain:      |

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Youth Service Organization

Volunteer and/or Paid Experience with Children

List any formal experience within the last 5 years that you were with for 3 months or longer

Name of Organization:

Address:

Contact Person:

Phone number:

Email:

Dates of Experience:

Number of Children:

Ages of Children:

Responsibilities:

Name of Organization:

Address:

Contact Person:

Phone number:

Email:

Dates of Experience:

Number of Children:

Ages of Children:

Responsibilities:

STATEMENT OF UNDERSTANDING AND AUTHORIZATION

The Big Brothers Big Sisters One-to-One Program is an interfaith and interracial program. The agency does not discriminate in any way. However, the desires of the child’s parent or guardian are respected in the selection of an appropriate adult for each child. All information regarding health, personality, behavior, and sexual orientation shall be held in confidence with the exception of information deemed relevant to the match process by the professional staff. Agency staff will share with the parent or guardian any information relevant to the match, while withholding the volunteer name until the actual match is made. Any party has the right to refuse to enter into the match based upon information communicated by the agency staff.

I understand that:

1) The references I listed may be contacted by mail, telephone, or email;

2) This in no way obligates me to perform any volunteer services;

3) 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;

4) The BBBS agency is not obligated to match me with a youth; and,

5) As part of the BBBS enrollment processes, BBBS will ask me to provide additional personal information prior to making any recommendations for assignment.

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

“I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION.”

I have the right to make a request to the consumer reporting agency: AmericanChecked Inc., 4870 South Lewis Avenue, Suite 120, Tulsa, OK  74105; telephone:  800-975-9876(“Agency”), upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information and the agency, on our behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by the investigative consumer report(s); and the recipients of any reports on me which the agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years).  I hereby consent to your obtaining the above information from the agency.  You may view their privacy policy at their website:  .

 

I hereby authorize procurement of consumer report(s) and investigative consumer report(s).  If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

 ♦    California, Minnesota and Oklahoma Applicants only:  Check box if you request a copy of any consumer report ordered on you.

I acknowledge that I have been provided a copy of consumer’s rights

under the Fair Credit Reporting Act. Yes No

I understand Statement of Understanding and Authorization Yes No

I understand that my signature is indication of my acceptance of said terms Yes No

           

Name/Signature Date

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