BIG HOPE Volunteer Application

BIG HOPE Volunteer Application Personal Information First Name:

Middle Name:

Home Address:

Last Name:

Apt#

Maiden Name : City:

County:

Home Phone #:

Work Phone #:

Cell Phone:

Date of Birth:

Gender:

Marital Status:

Male Female

Preferred Name to be called: State:

Zip:

Best time to call? Home Work Cell Nationality:

Ethnicity:

Email address: Applicant Occupation and Title:

Employer:

Address:

City:

State:

How Long Employed:

May we contact you at work?

Highest Education Degree Earned (minimum of HS required):

Are you currently a college student?

Social Security #:

Yes

DL #:

Have you previously applied to be or have you been a Big Brother or Big Sister? Yes No

Work Hours:

No Yes

Zip:

If yes, name of school:

No

DL State Issued:

Graduation Year:

DL Expiration date:

If yes, where:

Former staff member/MSS name, number and email:

When:

Former Little’s Parent name, number and email:

How did you hear about Big Brothers Big Sisters? Current Military Status:

Active Duty

Reserve

Veteran

Retired

Cadet

None

Other____________________

N/A

Are you interested in learning about additional ways to contribute to Big Brothers Big Sisters’ Mission? If yes – select interests that apply: Be a Donor Recruitment Volunteer Event Volunteer Fundraising Volunteer Invite BBBS to speak at your company Volunteer Youth Experience: Organization Name(s): Contact Name /Phone #: List any other organizations with contact info, where you worked and/or volunteered directly with youth within the last 5 years.

Please list previous volunteer activities: ___________________________________________________________

______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Please indicate for what role(s) you would like to volunteer: _______ Prayer partner _______ Occasional special projects _______ Regular mentor (If so, please identify who you will ask to be your prayer partner):________________ _______ Substitute mentor If you are applying to be a prayer partner and or Special projects, your application is complete. Please return this to the KIDS HOPE director at your church. Prayer Partners & Special projects do not have to complete the screening process and reference checks unless they are considering being with a child at a future date. Mentors and Substitute Mentors are required to complete the additional information, below the dotted line, as part of the volunteer screening process. ***For promotional purposes, videos and photographs may be taken during the KHUSA mentoring hour or at KHUSA event. Occasionally, a photo of you may be shared with the KHUSA National Office to appear in the volunteer newsletter called Voices of Hope. Your application constitutes permission for KHUSA to use your picture in promotional material.

Please indicate the days and times you are available to give one hour: Monday Tuesday Wednesday

Thursday

Friday

a.m.

a.m.

a.m.

a.m.

a.m.

p.m.

p.m.

p.m.

p.m.

p.m.

Big Brothers Big Sisters

Big Hope Volunteer Application- August 2016

BIG HOPE Volunteer Application References- Provide the required four different types of references that have each known you at least two years. For each listed reference, if first listed relation does not apply to you, then move to next relation (not next reference) until applicable. Remember to select relation and specify years known for each listed reference. Reference Relation to Applicant: Spouse/Spousal Equivalent (Required if applicable) Parent Sibling Other Family Relative:________

Reference Name:

Phone Numbers/ext: Email Address:

Years known: Min 2 YRS

Cell: Other:

_____ YRS

current or past employer current or past coworker Business Colleague School (Prof/Counselor/Admin)

Cell:

Friend Neighbor

Cell: Other:

_____ YRS

Friend Coworker Other: _____________

Cell:

Min 2 YRS

Other:

_____ YRS

Min 2 YRS

Other:

_____ YRS

Min 2 YRS

I hereby certify that the information provided in this application is true and complete to the best of my knowledge and subject to verification by the agency. I authorize the agency, its affiliates, and their representatives to investigate all information given and to secure additional information, if necessary. I understand that any misrepresentation or omission of a material fact on my application or during my interview process may be justification for refusal of volunteer placement, or if placed, will be grounds for dismissal without advance notice.

I understand that and consent to the following: 1) 2) 3)

The references and youth organizations I listed may be contacted by mail, telephone, text or email; I am in no way obligated to perform any volunteer services; I will notify my references and any youth serving organization that they should comply with Big Brothers Big Sisters request to complete a reference; 4) The information I provided may be used to conduct a background check now and for as long as I am involved with the agency, to include driving records check, sex offender check, criminal background check, public domain check, and other records where required by local, state, or federal law for volunteers working with youth; 5) In order for Big Brothers Big Sisters Lone Star (BBBSLS) agency to provide responsible and professional services, it is necessary for me, the volunteer, to disclose personal information. 6) All records are considered property of the agency, not of agency staff, clients, parents/guardians, volunteers or authorized persons or representatives; Information from the application interview process, or match support process may be shared between BBBS and partnership agencies when applicable; 7) Volunteer Big Brothers and Big Sisters, as well as the children BBBS serves, their parents/guardians, and BBBS staff and Board Members, are not excluded on the basis of race, religion, national origin, color, gender, marital status, sexual orientation, gender identity, veteran status, or disability; 8) Parents are given the opportunity to express volunteer preferences in a match and those preferences are honored; 9) I must complete a training prior to being matched with a youth; 10) BBBS is not obligated to match me with a youth; 11) If I am accepted as a Big Brother/Big Sister, I understand my obligation to meet with my Little Brother/Sister regularly and to inform BBBS agency staff as to the status of my match relationship every month. I further agree to accept the supervision of the BBBS staff and discontinue my service if I am requested to do so; 12) I understand Big Brothers Big Sisters has a ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously. BBBS will cooperate fully with the authorities to investigate all cases of alleged abuse

I have read the above statements and accept them as conditions of volunteering. Signature (Please do not print or type signature) Parent Signature (if under 18yrs - for Big Family use only)

Date Date

Please return this completed application with a copy of your driver’s license along with the completed Authorization for Background Check form to your church’s BIG HOPE Director Big Brothers Big Sisters


BIG HOPE Volunteer Application NOTICE AND AUTHORIZATION FOR BACKGROUND CHECK NOTICE This is to inform you Big Brothers Big Sisters (“BBBS”) may obtain information about you and/or your history related to potential criminal activity. The report from authorized sources may include, among other information, arrest, conviction, and driving record information. BBBS may additionally obtain information concerning your background, character, medical conditions, employment, education, and military experience. Information obtained by BBBS will be used only for the purposes of assessing your suitability to become a volunteer and matching you with a Little Brother or Little Sister.

AUTHORIZATION I hereby authorize and instruct BBBS to procure a report on me, including a criminal background history, which I understand may include, among other information, arrest, conviction, and driving record information. I also authorize and instruct BBBS to verify my Social Security number and to investigate my background and character in any manner they see fit to evaluate my potential as a Big Brother or Big Sister, including obtaining information from medical providers, employers, educational institutions, military agencies, and any other sources. If I become a volunteer for BBBS, I authorize BBBS to repeat these investigations at any time for as long as I remain a volunteer. I authorize BBBS to disclose relevant information obtained from its investigations to the parent/legal guardian of any child considered as a possible Little Brother or Little Sister to effectively enable the parent to exercise “parental choice” in accepting or denying me as a Big Brother or Big Sister for their child. I authorize and instruct any individual, corporation, and public or private entity having knowledge about me to furnish to BBBS any and all information they may have regarding me. I unconditionally release and hold harmless BBBS and its officers, directors, employees, and agents and any party furnishing information to them pursuant to this authorization from any liability, claims, charges, costs, or causes of action which I or my heirs, executors, or assigns may have as a result of the delivery, disclosure, non-disclosure, or omission of any information. I additionally agree to indemnify BBBS and its officers, directors, employees, and agents for any and all attorney fees, court costs, and other expenses resulting from investigating my background, gathering information concerning me, or verifying personal information about upon the written request of law enforcement agencies. Furthermore, I understand that BBBS holds the right to deny my participation in the program and, for confidentiality, is not required to disclose reasons for doing so. A photocopy of this authorization may be accepted in lieu of the original. __________________________________________

_____________________________________________________

Date

Signature (please do not print or type) PERSONAL IDENTIFICATION AND BACKGROUND INFORMATION

PLEASE PRINT: Complete, Legal Name:

Gender: M

F

If name changed (through marriage or otherwise), print former name Date of Birth

Social Security Number

Drivers License Number _____________________________________ State ___________ Expires____________________ Please list all residences from the last 7 years, starting with the most current. List the beginning and end month and year you lived at each (ex. Dallas, TX Dallas 3/09-6/10) City_______________________ State ____ County_____________ Beginning Month/Year: ______ End Month/Year: ______

City_______________________ State ____ County_____________ Beginning Month/Year: ______ End Month/Year: ______

City_______________________ State ____ County_____________ Beginning Month/Year: ______ End Month/Year: ______

City_______________________ State ____ County_____________ Beginning Month/Year: ______ End Month/Year: ______ Have you ever been (circle which) charged with / convicted of a (circle which) misdemeanor / felony? No

Yes

Details: Are you active or retired in the military? ___________ If yes, please submit a copy of your DD-214 form. Have you ever been cited for a traffic violation? No_____ Yes_____ Details: For the safety of all children and volunteers, BBBS conducts a background check on all potential volunteers. Big Brothers Big Sisters


Texas Dept. of Family and Protective Services

BIG HOPE Volunteer Application Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors

Form 2970c August 2012

Any person who will have direct contact with a Department of Family and Protective Services (DFPS) client or access to DFPS client information must complete this form. 1. Have you ever been convicted of or pleaded “guilty” or “no contest” to a felony or misdemeanor as an adult or juvenile? Include deferred or probated adjudications as well as convictions that have been set aside. Yes No If yes, give details including date, location and nature of the offense and disposition for each such incident. 2. Are you currently charged with (indictment or official criminal complaints by county or district court) a felony or misdemeanor? Yes No If yes, give details, including date, location, and type of charge. 3. Have you been or are you currently being investigated for allegedly abusing, neglecting, or exploiting a child, an elderly person, or a person with disabilities? Yes No If yes, give details, including the state and county in which each such investigation occurred. I declare the information provided on this statement is true and correct. I understand that any misrepresentation or omission of the information requested may result in my being barred from providing direct services or accessing DFPS client records under a contract with DFPS. I also agree to inform the contractor, who will in turn notify the DFPS contract manager, if I am named in complaints, indictments, or convictions of offenses as described in items 1 & 2, or if I am investigated for allegations as described in item 3 of this form. I authorize DFPS to verify any information provided by me through the investigative records maintained by DFPS and any other state protective services agency, as well as records of any law enforcement agency, including the Texas Department of Public Safety and the Federal Bureau of Investigation. I consent to DFPS’ disclosure of any and all information, including confidential information, obtained from the above-referenced sources to the contractor listed below in order to facilitate my employment, subcontracting or volunteer service with such contractor.

Printed Name of Person Completing Form

Date Signed


Signature of Person Completing Form


23393446

Contractor’s Name

Contract #
