| Personal Info |
| First Name: |
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| Middle Name: |
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| Last Name: |
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| Home Phone: |
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| Cell Phone: |
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| Email: |
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| Ethnicity: |
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| Gender: |
Male Female |
| Birth Year: |
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| Speak language other than English: |
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| Employment Info |
| Employer: |
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| Title: |
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| Address: |
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| Work Phone: |
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May we call
you at work? |
Yes
No |
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| Residential History |
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Please list your current residences. The information you provide will be used to conduct a criminal records background check through various local, state, and national databases. |
| Current Home Info |
| Address: |
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| City: |
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| County: |
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| State: |
Zip: |
| From Date: |
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| To Date: |
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| References |
Please DO NOT list any relatives as references even if they fit one of the reference types. If you have been in counseling in the past two years, please list your counselor. Please list your supervisor if you are employed.
Community Program: all three references are required; please list friends, co-workers, or others if the above does not apply to you.School Based Program: you only need to fill out two (2) reference.
Please provide your references email addresses where available as this helps us save time and resources by automatically contacting them when you submit this form. |
| Professional Reference - Supervisor or teacher who has known you for at least ONE year |
| Type: |
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| Name: |
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| Address: |
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| Phone: |
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| Fax: |
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| Email: |
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| Coworker or Friend - Who has known you at least THREE years |
| Type: |
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| Name: |
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| Address: |
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| Phone: |
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| Fax: |
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| Email: |
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| Coworker or Friend - Who has known you for at least ONE year |
| Type: |
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| Name: |
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| Address: |
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| Phone: |
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| Fax: |
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| Email: |
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| Program Interests |
| Program interest: |
Community Program
School Based
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Other: |
| Please tell us how you heard about BBBS: |
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Other: |
| Have you ever applied to Big Brothers Big Sisters? If so, where and when? |
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| Comments |
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By submitting this form, I am indicating that I understand and agree to the following:- The references I listed may be contacted by mail, telephone, or email
- This application in no ways obligates me to perform any volunteer services
- 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
- Our BBBS agency is not obligated to match you with a youth
- As part of our enrollment processes, we will be asking you to provide additional personal information prior to make any recommendations for assignment.
- I authorize my counselor (if applicable) to release any pertinent information contained in my records or files regarding my suitability to be a volunteer for Big Brothers Big Sisters of San Juan County which by law or otherwise, may be considered confidential or privileged. This consent expires when I have fulfilled my commitment to the Big Brothers Big Sisters of San Juan County and when I am no longer an active volunteer. I release the above named from any damages because of furnishing such information.
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