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CB SB SB+ HS Big

Big Brothers Big Sisters of Mohave County

VOLUNTEER APPLICATION
Thank you for your interest in becoming a Big Brother or Big Sister. Please submit completed application via email to
mhuggett@lhcinteragency.org or fax to 928-453-2787; or hand deliver or mail to 1940 Mesquite Avenue, Lake Havasu
City, AZ 86403.
Along with this application, you will need to submit a copy of a government-issued photo ID, as well as your drivers
license (if not used as your government-issued photo ID), and proof of auto-insurance, if you plan to transport a child
within the community-based program. All applications will be given equal consideration regardless of race, age, sex,
disability, marital status, sexual orientation, religion or national origin.
GENERAL INFORMATION
First Name:

Middle Name:

Last Name:

Preferred Name :

Home Phone #:

Work Phone #:

Cell Phone #:

Is it okay to text you?

Cell phone Provider:

Home Address:

Personal E-mail:

City:

County:

Work E-mail:

State:

Yes

Zip:

How do you prefer to be contacted?

(Phone, e-mail, time of day, etc.)

Social Security Number:

Gender:

Marital Status:
If applicable, maiden name:

Date of Birth:
Race/Ethnicity:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White

Other
Multi-race (check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other

Nationality/Country of Origin:

Occupation:

How Long Employed?

Highest Level of Education:

Work Hours?

Are you a student at this time?

If yes, please name school:

Yes

Area of Study:
Do you have current or past military experience?

Branch:

Air Force

No

Army

Yes

Marine Corps

Dates of Service:

No
Navy

Coast Guard

No

Component:
Active

Are you retired?

Yes
No
Are you separated/discharged (other than retired)?
Yes
No
If retired, separated, or discharged, please check the character of separation/discharge:
Honorable
General (under honorable conditions)
Under Other than Honorable Conditions
Bad Conduct
Dishonorable

National Guard

Reserve

Possession of a drivers license is required if you will be transporting a program youth in any vehicle you are operating.

Do you have a current and

valid drivers license?
Yes

No

If yes, state of issue and #:

Do you have a vehicle?

Yes
No

Expiration date:

Do you have valid insurance that meets or

exceeds state required minimum?
Yes

No

Have you previously applied to be or served as a Big Brother or Big Sister here or anywhere else?
If yes, when and where?
Have you ever been involved with Big Brothers Big Sisters in a capacity other than a Big?
If yes, when and where?
Have you ever been involved with or volunteered for another youth organization?
If yes, when and where?

Yes

Yes

Yes

No

No

No

Have you ever been denied acceptance or released from service as a volunteer or employee for another Big Brothers Big
Sisters program or youth-serving organization?
Yes
No
If yes, when and where?
Are you interested in learning about additional ways to contribute to the Big Brothers Big Sisters mission?
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

Yes

REFERENCE INFORMATION
Please list information for at least three references below including:
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);
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; AND
3. A friend or neighbor you have known for at least two years.
Spouse/Partners name:

Family member name (if no spouse/partner):

Address:

City:

Day Phone #:

Cell #:

State:

Zip:

Email:

Employer or Co-worker (current or past) or school personnel (if you are a student):
Address:

City:

State:

Zip:

No

Day Phone #:

Cell #:

Email:

Friend, Neighbor, or other personal reference:

Address:
Day Phone #:

City:
Cell #:

State:

Zip:

Email:

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. Please list additional on separate page, if needed.
Organization name:

Direct supervisor:

Address:

City:

Day Phone #:

Cell #:

State:

Zip:

State:

Zip:

State:

Zip:

Email:

Dates of involvement/employment:
Reason for leaving:
Organization name:

Direct supervisor:

Address:
Day Phone #:

City:
Cell #:

Email:

Dates of involvement/employment:
Reason for leaving?
Organization name:

Direct supervisor:

Address:
Day Phone #:

City:
Cell #:

Email:

Dates of involvement/employment:
Reason for leaving:

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) Other BBBS agencies and youth organizations where I have worked or volunteered may be contacted as references;
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 childs 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) I agree to timely communication and follow-up with all agency staff.

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 information that 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 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 occurrences. I understand that BBBS staff needs to be fully informed to provide the best guidance or support
possible.
Signature __________________________________________ Date _________
If applicant is under the age of 18, co-signature of a parent/guardian is required for application and to obtain
criminal history record check information:
Parent/Guardian Name: _______________________ Signature: _______________________ Date _____________
[Agency may wish to insert other policy notices or release here, e.g., confidentiality policy, photo/video release form]

VOLUNTEER PRE-INTERVEW QUESTIONNAIRE

Prior to your in-person interview, please answer the questions below. Parents of youth in our programs will often ask
questions about someone with whom their child will be matched. The information you provide will also help us make a
better match for you and assure we can support you during your involvement with our program. Please note that you will
have an opportunity to discuss these questions and your responses more thoroughly during your in-person interview.
Name: ____________________________
1. Do you have any concerns about your ability to fulfill the 12-month commitment required of mentors?
Yes
No
2. Do you anticipate any significant life changes over the next year or had any this past year?
Yes
No
Please describe:
3. Have you ever been accused, arrested, charged, or convicted of a crime?
Yes
No
4. Have you had any driving citations and/or moving violations in the past 5 years?
Yes
No
5. Do you have guns, ammunition, or other weapons in your house?
Yes
No
6. Are you experiencing any physical or mental health issues?
Yes
No
7. Do you speak any foreign languages?
Yes
No
8. Is there anything else youd like to tell us about yourself or any questions that you have?
9. Are there other people living in your household?
Provide name, age, relationship to you.
Name:

Age:

Relationship:

Name:

Age:

Relationship:

Name:

Age:

Relationship:

Name:

Age:

Relationship:

10. Please list any counties and states that you have lived in aside from your current address in the past 5 years.

I have answered these questions honestly and completely to the best of my knowledge.
__________________________________________________
Signature

_________________________
Date

[Agency may wish to insert other policy notices or release here, e.g., confidentiality policy, photo/video release form]