| Date
Submitted: |
|
| Name: |
*
|
| Date
of Birth: |
*
|
| Race: |
*
|
| Address: |
*
|
| City: |
*
*
Zip:
*
|
| Home
Phone Number: |
*
|
| Email
Address: |
*
|
| Employer
Name: |
*
|
| Employer's
Address: |
*
|
| City: |
*
*
Zip:
* |
| Time
at Present Employer: |
*
|
| Business
Phone: |
*
|
| Marital
Status: |
*
|
| Spouse's
Name |
|
| Spouse's
Occupation: |
|
| Roommate's
Name: |
|
| Children's
Names and Ages: |
|
| With
whom do your children live? |
|
| Have
you ever applied to be a mentor before? |
*
|
| Have
you been a mentor before? |
*
|
| If
so, where and when? |
|
| How
did you hear about Big Brothers Big Sisters? |
*
|
| Have
you ever been arrested? |
*
|
| If
yes, please explain: |
|
| Have
you ever been convicted of a criminal offense? |
*
|
| If
yes, please explain: |
|
| Your
age preference for a Little Brother/Sister: |
*
|
| Do
you have race preferences? |
|
 |
| Please
list four people (non-related) who have known you for at least
two years and know you well enough to vouch for your character
and/or your ability to work with children. Out of town
references are acceptable. |
| Name: |
|
| Address |
|
| City |
Zip:
|
| Phone: |
|
| Fax: |
|
| Email: |
|
|
| Name: |
|
| Address |
|
| City |
Zip:
|
| Phone: |
|
| Fax: |
|
| Email: |
|
|
| Name: |
|
| Address |
|
| City |
Zip:
|
| Phone: |
|
| Fax: |
|
| Email: |
|
|
| Name: |
|
| Address |
|
| City |
Zip:
|
| Phone: |
|
| Fax: |
|
| Email: |
|
|
|
| In
determining whether a child or volunteer may be considered
for a match and what information will be communicated to each
party involved, due consideration is given to past and present
factors. These factors include the health, personality, and
behavior of each individual and/or family constellation, which
the professional staff of the agency feels may have an adverse
effect upon the relationship. Any person has the right to
refuse to accept a proposed match based upon the information
that is provided to him/her.
I hereby
certify the preceding information to be true and correct.
I understand that all of the information, which I have given
and will give to the professional staff member of the agency,
may be substantiated by the Big Brothers Big Sisters agency.
I also understand that the agency may examine my employment
records, my background of psychological counseling, and
any records of law enforcement agencies that pertain to
me. I understand that all information will be held in the
strictest of confidence, except for informing my potential
Little's guardian of relevant information. I understand
and agree that I am not obligated, if called upon, to perform
the services of a Big Brother or Big Sister and that the
Big Brothers Big Sisters agency is not obligated to assign
or actively seek to assign a child to me.
I do
hereby give consent for BBBS of the Heart of Georgia to
share with my potential match mate and parent a summary
of information concerning my family background, values,
interest, etc. I understand that I will not be identified
by name until after the match has been agreed upon by both
volunteer and parent. This consent will remain in effect
until a match is formalized or until I personally request
it to be canceled.
|
| *
|
I
agree with all statements in the above paragraphs. I
also understand that my signature will be required prior to
a child being assigned to me. |
| |
|
