BIG BROTHERS BIG SISTERS OF SOUTH SIMCOE
Traditional Big Brother/Big Sister
In-School Mentoring
Big Bunch Group Program
Seniors Program
Date: _________________________________
Full Name: ______________________________________________________________
Address: ________________________________________________________________
Postal Code: _____________ Home Phone #: _____________ Work Phone # _________
How long at current address? ______________________________
Previous address if less than one year: ________________________________________
Age: _________________ Date of Birth: ____________________________________
Do you own or have access to a vehicle? ______________________________________
If yes, Driver’s License Number: ____________________________________________
Does your car have passenger – side airbags? Yes No
What is the level of your automobile insurance coverage? _________________________
Employment
Employer: _______________________________________________________________
Position: ________________________________________________________________
Work Address: ___________________________________________________________
Work Phone: _________________________ ext: ______ Can we call you at work? ____
Length of Time at present employment: _______________________________________
Working Hours: _____________________________
Family
Martial status: single married separated
divorced common-law widowed
Partner’s Name: _____________________________________
Partner’s Place of Business: _________________________________________________
Number of Children __________ Ages of girls ___________ Ages of boys ___________
What changes in your family status do you anticipate in the coming years? ___________
How does your partner feel about you becoming a volunteer with Big Brothers Big Sisters of South Simcoe? ___________________________________________________
Education
Education Level: High School Trade School College
University Other: ___________________________
Name of last school attended: _______________________________________________
Are you presently a student? Yes No
Other
Have you ever been in trouble with the Police? Yes No
If yes, please explain and provide dates: _______________________________________
Have you ever been accused, arrested, convicted or pardoned of a sexual offense involving a child or children? Yes No
If yes, please specify ______________________________________________________
Have you ever been, or applied to be a volunteer with a Big Brothers Big Sisters agency in the past? ____________________ If so, where and when? ______________________
Are you a member of any other clubs, affiliations or organization? If so, please list them. _______________________________________________________________________
What are your interests, hobbies or activities? __________________________________
How long have you been thinking about becoming a volunteer with this agency? (i.e. a week, a month, a year etc.)? _________________________________________________
How did you hear about this program? ________________________________________
Why do you want to become a volunteer in the program now? _____________________
References
Please provide the names and address of three character references that have known you for at least two years. We ask that at least one reference be of a professional contact.
NAME: _______________________________________________________________________________
ADDRESS: ________________________________________________APT #- _____________________
TOWN/CITY: _________________________________________ POSTAL CODE: _________________
PHONE NUMBER _____________________________________
RELATIONSHIP TO APPLICANT: ________________________________________________________
NAME: _______________________________________________________________________________
ADDRESS: ________________________________________________APT #- _____________________
TOWN/CITY: _________________________________________ POSTAL CODE: _________________
PHONE NUMBER _____________________________________
RELATIONSHIP TO APPLICANT: ________________________________________________________
NAME: _______________________________________________________________________________
ADDRESS: ________________________________________________APT #- _____________________
TOWN/CITY: _________________________________________ POSTAL CODE: _________________
PHONE NUMBER _____________________________________
RELATIONSHIP TO APPLICANT: ________________________________________________________
I certify that the above information is correct. Further, I understand that filling out this application puts me under no obligation but merely expresses an interest. Also, I understand that should my references indicate personal attributes not acceptable to the organization, the application process shall be terminated. The agency is under no obligation to accept or assign the applicant and this file is the property of this agency.
However, if I am accepted, I understand that Big Brothers Big Sisters of South Simcoe are responsible for the welfare of any child who may be entrusted to my care. I hereby grant them permission to assign a child to me in a Little / Big relationship. I also grant them permission to terminate this relationship, as they deem necessary. I also agree to abide by the philosophy, goals and general policies of Big Brothers Big Sisters of South Simcoe.
DATE: __________________________ SIGNATURE: _________________________________________
Please complete and return to: Big Brothers Big Sisters of South Simcoe, Attention: Case Coordinator
Box. 504, 54 Queen St. South, Tottenham, ON., L0G 1W0
Fax: 905-936-2412