Pre-enrollment Questions

 

Name _______________________________Date of Birth ________________

Address_________________________________________________________

City _________________State _____________ County_________ Zip Code__________

Email ____________________________ Home phone ____________

Work phone_____________ Cell phone ____________ Fax _____________

Social Security __________________ Male/Female Employer _____________________

Work Address_________________________________________________________

City _________________State _____________ County_________ Zip Code__________

Occupation _____________________ Ethnicity _________________________

Can we contact you at work?       Yes/No                    Work Hours: ______________

How long employed? _______________

 

Possession of a driver’s license is not a requirement to participate in any of our programs but is required if you will be transporting a youth in any vehicle you are operating.

 

Do you have a driver’s license?  Yes/No   If yes…State of Issue ___________ Number__________ Expiration date ______________

 

Please type or print information requested for three references:

your current or past employer who has known you for at least 1 year.

a co-worker or friend who has known you for at least 2 years, and

a close family member (spouse/domestic partner) or a second friend who has known you for at least 3 years.

 

1.              Employer's Name (or school if student)__________________________________

                 Supervisor's Name (or teacher if a student)_______________________________

                 Address___________________________________________________________

                 City ________________________State _____________ Zip Code____________

 

2.              Coworker or Friend _________________________________________________

                 Address___________________________________________________________

                 City ________________________State _____________ Zip Code____________

                 Daytime phone # _____________________ Email_________________________

 

3.              Spouse/Domestic Partner/Friend _______________________________________

                 Address___________________________________________________________

                 City ________________________State _____________ Zip Code____________

                 Daytime phone # _____________________ Email_________________________

 

Have you ever applied before (or have been) to be a Big Brother or Big Sister?

 Yes             No

 

Where and When ___________________________________________

What, if any, other youth organizations have you worked for or been involved with as a volunteer?_______________________________________________________________________________________________________________________________________

 

 

I understand that:

 

1)   The references I listed may be contacted by mail, telephone, or email.

2)   This enrollment in no ways obligates me to perform any volunteer services.

3)    The information I provided may be used to conduct a background check, to include driving records.

4)    The BBBS agency is not obligated to match me with a youth; and

5)    As part of our enrollment processes, we will be asking you to provide additional personal information.

 

 

_________________________________________________   _____________________

Signature                                                                                                     Date

How to apply: The easiest and fastest way to get started is to print and complete this form.  After you complete the form please mail or bring it to your local office, a Big Brothers Big Sisters staff member will contact you. If you have questions please contact your local office or go to Matches in a Nutshell.  You'll need to:

 

·     Participate in an in-person interview

·     Provide three references

·     Participate in three background checks

 

Pre-enrollment Questionnaire

 

Name _________________________________  Date ______________________

 

1. Which do you enjoy more?     Indoor Activities       Outdoor Activities

2.    Would you describe yourself as someone who enjoys…

 Watching events and activities   Actively participating in Activities    Both

3.     In identifying a youth for you to work with, are there any special considerations

 You want us to know about?  No    Yes _________________________________

 _________________________________________________________________

4.   Do you have guns or ammunition in your house?  No    Yes….How are they kept?

         __________________________________________________________________

       __________________________________________________________________

5.   Would you be able to secure or otherwise make unavailable any youth

        inappropriate viewing materials in your home?  This would include television channels and Internet access?                                      No   Yes

6.   Do you have any pets in your home that could potentially scratch or bite a child?

             Yes     No

7.   Are you experiencing any medical problems/issues that could affect a match of which we should be aware of?   No   Yes…_______________________________

       __________________________________________________________________

8.   Do you anticipate any significant life changes over the next year or have you had any in the past year?   No     Yes…if so please explain ______________________

       __________________________________________________________________

9.   Would you be willing to work with a child who had experienced physical, emotional, or sexual abuse?   No    Yes

10.  Do you speak any foreign languages?   No    Yes _________________________

Before we continue with some additional questions about your personal background and life, is there anything else you'd like to tell us about yourself or any questions you may have for us? ____________________________________

____________________________________________________________________________________________________________________________________

 

 

_______________________________________________   _________________

Signature                                                                                                                                       Date