Dear Community Member,
We appreciate your interest in Big Brothers Big Sisters of Henry County. Being a Big Brother/Sister is one of the most rewarding and enjoyable things you will ever do! Our mentoring program is all about one-on-one time spent with the Big and the Little doing things he/she enjoys. Spending as little as six hours a month with your Little has the power to change their life! Please review this information and feel free to contact the office at 529-4494, should you have any questions.
Enclosed is a Volunteer Application, a Proof of Insurance and Release of Information form, a Release for a Police Review as well as a Pre-Interview Questionnaire. Please return the completed forms in the self-addressed, stamped envelope or return it to our office at your earliest convenience. Please keep in mind that we must have all forms completed and returned to our office before we can move forward with the match process.
You will also notice a small sheet of paper asking for your help. Do you know of someone who you think would be a great Big Brother or Big Sister? If so, please consider sharing their contact information with us, and return it with the other paperwork.
Thank you again for your interest in Big Brothers Big Sisters of Henry County. I look forward to meeting with you!
Sincerely,
Casey E. Knight
Enrollment and Match Support Specialist
PRE-INTERVIEW QUESTIONNAIRE FOR VOLUNTEER
Prior to your in-person interview, we would like you to answer the questions below. Parents of youth in our programs will often ask us questions about someone with whom their child will be matched. We will only release information to a parent with your expressed permission. The information you give will also help us make a better match for you and assure we can support you during your involvement with our program.
Your Name: Date:
1. What is your marital status?
r Single r Married r Divorced r Domestic Partner r Widow
What is your sexual orientation?
r Heterosexual r Homosexual r Bi-Sexual
What is your religious affiliation?
What is your place of worship?
2. What is the highest level of education you’ve attained?
School: Date(s):
3. Do you own an automobile? r Yes r No
If yes, and if you will be transporting a Little in your vehicle, we will need a copy of your current insurance card.
4. Which do you enjoy more? r Indoor Activities r Outdoor Activities
5. Would you describe yourself as a person who enjoys:
r Watching events/activities r Actively participating in them r Both
6. In identifying a Little for you to work with, are there any special considerations you want us to know about yourself? r No r Yes
7. Do you have any guns or ammunition in your home?
r No r Yes; where are they stored?
8. Are there any inappropriate viewing materials in your home? This would include television channels and Internet access.
r No r Yes; please explain.
9. Do you have any pets? r No r Yes
Could they potentially scratch or bite a child? r No r Yes
10. Are you experiencing any medical problems/issues that could affect a match and that we need to be made aware of?
r No r Yes; please explain:
11. Have you ever been arrested or convicted of a crime or have ever had a DUI and/or any traffic violations in the past 3 years?
r No r Yes; please explain:
12. Do you anticipate any significant life changes over the next year or have you had any in the past year?
r No r Yes; please explain:
13. Would you be willing to work with a child who had experienced physical, emotional or sexual abuse?
r No r Yes
14. Have you ever been or are you currently being investigated for allegedly abusing, neglecting, or exploiting children, the elderly or the disable? r No r Yes
If yes, please list details including the degree, city, state, and county of the event.
15. Are you in the military: r No r Yes; Branch:
Duty Station: Rank:
16. Anything else you would like to share with us?
Applicant’s Signature: Date:
VOLUNTEER INTERESTS / ACTIVITES
Name: Date:
1. What sports do you like to watch?
2. What sports do you like to participate in?
3. What activities/hobbies do you like to do when you are outdoors?
4. What activities/hobbies do you like when you are indoors?
5. What social organizations do you belong to?
Favorite Restaurant:
Favorite Food:
Favorite TV Show:
Favorite Place to Go:
INTERESTS / ACTIVITIES
Please circle the activities that you participate in on a regular basis.
WALKING MUSEUMS TENNIS
HIKING PLAYS RACQUETBALL
BIKE RIDING CONCERTS HOCKEY
------SINGING BOWLING
CAMPING DANCING POOL
FISHING MUSICAL VOLLEYBALL
HUNTING INSTRUMENTS ------
PICNICS ------WATER SKIING
BOATING GAMES JET SKIING
------PUZZLES SNOW SKIING
FARMING READING RACING
HORSES CARDS ROLLER SKATING
ANIMALS ------ICE SKATING
PETS GARDENING ------
NATURE SEWING PHOTOGRAPHY
------ARTS & CRAFTS CARPENTRY
TELEVISION COOKING ELECTRONICS
MOVIES SHOPPING WOOD WORKING
COMPUTERS ------AUTO MECHANICS
VIDEO GRAMES BASEBALL ------
------FOOTBALL OTHER:______
MODELS SOCCER ______
DOLLS SWIMMING ______
COLLECTIONS BASKETBALL ______
RUNNING/TRACK
Big Brothers Big Sisters of Henry County 1008 S. 14th St PO Box 464 New Castle, IN 47362 (765) 529-4494
Proof of Insurance Form
I understand that I am required to have adequate insurance coverage in order to become a Big Brother/Big Sister. I also understand that I am responsible to maintain this coverage during my involvement with this program.
Name of Insurance Company:
Name(s) of Insurance Agent:
Insurance Expiration Date:
Recommended Preferred My Coverage
General Liability $50,000 $100,000
Automobile Liability
A. Medical Payments $2,000 (per person) plus B or C
B. Bodily Injury $100,000 $250,000 (per person) (per occurrence) $300,000 $500,000
OR
Property Damage $50,000 $50,000
C. Single Limit of Liability $300,000
I understand that I am to maintain a current Indiana Drivers License.
Signature Date
Big Brothers Big Sisters of Henry County
Volunteer Application
First Name Middle Name Last Name
Home Address City Zip Code
Email Home Phone Cell Phone
Social Security Number Ethnicity Date of Birth
Possession of a drivers license is not a requirement to participate in any of our programs, but it is required if you will be transporting a youth in any vehicle you are operating.
Do you have a valid driver’s license? ¨ Yes ¨ No
Driver’s License Number Expiration Date
Marital Status (please circle): Single Married Divorced Separated Widowed Living Together
Significant Other’s First and Last Name
Children: Name Gender Age
What age child do you prefer? ¨ Elementary (age 6-12) ¨ Junior/Senior High (age 13-17)
Have you ever been convicted of a felony? ¨ No ¨ Yes
Do you object to Big Brothers Big Sisters of Henry County checking with the appropriate public authorities for matters of public record regarding your background and history? ¨ No ¨ Yes
Have you ever been a Big Brother or a Big Sister before? ¨ No ¨ Yes If yes, please give the name of agency and dates you volunteered:
Please complete other side.
Please list names and addresses of 4 personal references that have known you for at least 2 years, beginning with your current employer.
1. Employer: Supervisor’s Name:
Position: Working Hours:
Address:
Phone Number: Length of Employment:
May we contact you at work? ¨ Yes ¨ No
2. Name: Phone:
Address:
Email Address:
Relationship: Years Known:
3. Name: Phone:
Address:
Email Address:
Relationship: Years Known:
4. Name: Phone:
Address:
Email Address:
Relationship: Years Known:
I understand that:
1) The references I listed may be contacted by mail, telephone or email.
2) This application in no way obligates me to perform any volunteer services.
3) The information I provided will be used to conduct a background check, to include driving record check, criminal background check, and other records where required by local, state, or federal law for volunteers working with youth.
4) Our BBBS agency is not obligated to match you with a youth.
5) As part of our enrollment processes, we will be asking you to provide additional personal information prior to making any recommendations for match assignment.
6) The information provided on this application will not be shared with any outside agencies or organizations without your expressed written consent.
Signature Date
Big Brothers Big Sisters of Henry County 1008 S. 14th St PO Box 464 New Castle, IN 47362 (765) 529-4494
Release of Information
I understand that information given to Big Brothers Big Sisters of Henry County in the process of my becoming a Big Brother or Big Sister is confidential and will be kept in a locked file with access only to the professional staff.
I give Big Brothers Big Sisters of Henry County permission to share with the parent of a prospective Little Brother or Little Sister to be assigned to me, the information I have given to the degree the professional staff feel is necessary for the match to be made.
I give permission for Big Brothers Big Sisters of Henry County to use my picture and name for publicity.
Volunteer’s Printed Name
Volunteer’s Signature
Date
Big Brothers Big Sisters of Henry County 1008 S. 14th St PO Box 464 New Castle, IN 47362 (765) 529-4494
AUTHORIZATION FOR RELEASE OF INFORMATION
Your signature on this form authorizes Big Brothers Big Sisters of Henry County to secure a police review of your police record should any exist. As you may know, it is unlawful for the police to release the details of your record without your consent. Any indication of a police record will be held strictly confidential.
I HEREBYAUTHORIZE BIG BROTHERS BIG SISTERS OF HENRY COUNTY TO REQUEST AND RECEIVE A POLICE REVIEW CONCERNING ANY POLICE RECORD ON FILE.
Date of Birth: Social Security Number:
Volunteer’s Signature: Date:
*****************For Office Use Only*****************
POLICE REVIEW
RE:
The above named person has applied to be a Big Brother/Big Sister for Big Brothers Big Sisters of Henry County. If accepted, he/she will be assigned to work on a one-to-one basis with a child from our community. Therefore, it is necessary that any police record on file for this individual be indicated below.
YES NO Signature:
Title:
Date:
Big Brothers Big Sisters of Henry County
NEEDS YOUR HELP!
Do you know someone who you think would be a great Big Brother or Big Sister? Someone who is willing to spend a minimum of 6 hours a month with a child? Someone who understands the importance of a positive role model and mentor? If so, please consider sharing their contact information with us!
Name:
Address:
Phone:
Email:
Thank you!