Adult Big Application

Nationally Recognized As A Pinnacle Agency

Thank you for your interest in becoming a volunteer mentor.

Along with this application, you will need to submit a copy of a government-issued photo ID, as well as your driver's 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, gender identity, religion, or national origin.

Program Interest

First Name:

Middle Name:

Last Name:

Personal Pronouns:

Preferred Name:

Date of Birth:

Home Phone:

Home Address:

Work Phone:

City:

Cell Phone:

County:

Is it okay to text you?

State:

Zip:

Personal E-mail:

Work E-mail:

How do you prefer to be contacted?

Gender/Gender Identity:

Marital Status:

If applicable, maiden name:

Race/Ethnicity:

Languages Spoken:

Nationality/Country of Origin:

Tribal Affiliation:

Occupation:

Emergency Contact Name:

Emergency Contact Phone Number:

Employer:

Length of Employment:

Work Hours:

Highest Level of Education:

Area of Study:

Are you a student at this time?

If yes, please name school:

Do you have current or past military experience?

Dates of Service:

Branch:

Component:

Are you retired?

Are you separated/discharged (other than retired)?

If retired, separated, or discharged, please check the character of separation/discharge:

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

Do you have a current and valid driver's license?

If yes, state of issue and #:

Do you have a vehicle?

Do you have proof of auto insurance?

Have you ever been convicted of a crime other than a minor traffic violation?

If yes, please explain:

REFERENCES

Please provide the names and contact information of three personal references. References may include individuals who have known you for at least two years, such as friends, coworkers, neighbors, religious leaders, teachers, etc. Please do not include family members.

*Reference 1 - Relationship (Must Be Spouse or Family Member):

*Reference 1 - Name:

*Reference 1 - Phone:

*Reference 1 - Email:

*Reference 2 - Relationship (Must Be Spouse or Family Member):

*Reference 2 - Name:

*Reference 2 - Phone:

*Reference 2 - Email:

*Reference 3 - Relationship (Must Be Spouse or Family Member):

*Reference 3 - Name:

*Reference 3 - Phone:

*Reference 3 - Email:

*Have you held a volunteer or paid position where you worked with children in the last five years? (for example counselor at a camp, babysitting, nannying, coaching, etc.)

If you answered yes to the above question, please list references from those organizations. Please include name, organization, and contact email

Do you have any concerns about your ability to fulfill the 12 month commitment required of mentors?

Do you anticipate any significant life changes over the next year or have you had any this past year?

Have you ever been accused, arrested, charged, or convicted of a crime?

Have you had any driving citations and/or moving violations in the past five years?

Do you have guns, ammunition, or other weapons in your house?

What languages do you speak fluently?

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

I do consent to the use of identifying information and video, film and photographs in agency publications, promotional materials (including Facebook, Instagram & X formerly Twitter)YesNo

In addition to the references above, please list all youth serving organizations at which you have worked or volunteered in the past

COMMITMENT AGREEMENT

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer mentor, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

I authorize Big Brothers Big Sisters of Licking and Perry Counties to contact my references, and I give my permission for them to provide information about me. I release all parties from all liability for any damage that may result from furnishing this information to Big Brothers Big Sisters of Licking and Perry Counties.

I understand and agree that my volunteer status may be contingent upon the results of a criminal background check, including the use of fingerprints if necessary. I further understand that any information obtained as a result of the background check will be held in strict confidence.

I understand that if I am matched with a youth, I will be required to attend an orientation/training session and complete an interview with program staff. I also understand that if accepted as a mentor, I will be required to make a minimum one-year commitment to the program, spending a minimum of four hours per month with my mentee.

I understand that the information provided in this application will be used for background check purposes and will be kept confidential.

*Applicant's Signature:

*Date:

Contact Us

Business Hours

Day of Week	Start Time	Start Time AM/PM	Start/End Time Separator	End Time	End Time AM/PM
Monday	8:00	AM	-	4:00	PM
Tuesday	8:00	AM	-	4:00	PM
Wednesday	8:00	AM	-	4:00	PM
Thursday	8:00	AM	-	4:00	PM