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General Information

All information is confidential
Name: Address:
City, State, Zip: Email:
Home Phone: Work Phone:
Cell Phone:
Employer: Work Schedule:
Can you receive calls at work? Yes No Race:
Do you have a driver's license? Yes No State & #:
Birth Date: Marital Status:
Highest Level of Education:
How did you hear about our program?:
Have you applied with Big Brothers Big Sisters before? Yes No
If yes, when & where?:
Have you worked/volunteered with youth in the past year? Yes No
If yes, please list supervisor as a reference below.

Check the program for which you are volunteering (Big Couple or Big Family- each person must complete an application)
Big Brothers
Big Sisters
 Big Couple
Big Family
 Outdoor Adventure Mentor
Mother Mentor
 School Mentor

References
You have my permission to contact the following four people for reference checks. Yes No
  • References must have known you for at least one year (an exception may be made with teachers/supervisors).
  • One reference is required to be a supervisor or teacher (past or present).
  • Please include a complete mailing address for each reference.
  • No relatives please.

#1

Name of supervisor/teacher:
Street Address, City, State, Zip:
Area Code and Phone Number:
Relationship:

#2

Name of supervisor/teacher:
Street Address, City, State, Zip:
Area Code and Phone Number:
Relationship:

#3

Name of supervisor/teacher:
Street Address, City, State, Zip:
Area Code and Phone Number:
Relationship:

#4

Name of supervisor/teacher:
Street Address, City, State, Zip:
Area Code and Phone Number:
Relationship:

VOLUNTEER MEDIA RELEASE

I hereby consent to the use, sale, reproduction, transfer, or conveyance, of any and all photographs, images, likenesses, and voice recordings of me in all forms (with or without the use of my name) by Big Brothers Big Sisters of the Black Hills, or by any designee of the Agency.

I hereby consent to the use of all forms of media including advertising, trade, display, editorial, art, exhibition and Agency newsletters (with or without my photograph and/or my name). I hereby give this consent and release to Big Brothers Big Sisters of the Black Hills, their nominees and designees from liability for any violation of any personal or proprietary right and agree to hold Big Brothers Big Sisters of the Black Hills harmless from all liability from the use, sale, reproduction, transfer or conveyance of the aforementioned items.


I have read this document, understand it is a release of all claims, and CONSENT to the above.
I DO NOT give my consent

Statement of Understanding

If I am accepted as a mentor in any of the Big Brothers Big Sisters of the Black Hills’ programs, I understand my obligation to meet with my mentee regularly and to inform the Big Brothers Big Sisters agency staff as to the status of my match relationship. I further agree to accept the supervision of the agency staff and discontinue my service if I am requested to do so by the agency. I understand that all information that I have given may be substantiated by the Big Brothers Big Sisters agency and that all information is held in the strictest of confidence. I understand that any false information given by me may be grounds for termination of my match and/or ineligibility for the program and that completion of this application does not guarantee my placement into the program. I understand that Big Brothers Big Sisters of the Black Hills retains the sole and exclusive authority to induct people into the program in their sole discretion and as they see fit.


I understand and agree to the Statement of Understanding.
I would like further clarification of the Statement of Understanding.

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