Big Brothers Big Sisters Application

ALL INFORMATION RECEIVED WILL BE HELD CONFIDENTIAL IN EVERY RESPECT


Please indicate which program you are applying for: (Check as many as apply)
Community-Based Programs

Site-based Programs

Special Interests

Malisa's Hope (faith-based)
High School

1. *Name (first middle last)
2. Maiden Name (if applicable)
3. *Home Phone
4. Cell Phone
5. *Home Address
6. City
7. ZIP

8. *Email Address
9. How long at current address?
10. Driver's License #
State
11. Tag Number
Auto Insurance
12. Birth Date
13. Social Security #
14. Education Completed
15. Emergency Contact?
Contact's Address
16. Occupation
17. Employer or School
18. Squad & Rank (if applicable)
19. Business Phone
20. Permanent address
21.May we call you at work?
Best Times
22. City and State of Birth
23. Race
Sex
24. Marital Status Single Married Separated Divorced Widowed
25. Spouse's Name (if applicable)
26. Church or Congregation
27. Hunter's Education Card # (if app)

Have you applied to be a Big Brother or Sister anywhere before?
               If so, list agency, address and date

Please list names and numbers of anyone you know well, who is associated with Big Brothers Big Sisters:

Have you formally worked with children within the last three years? If so list organization, contact name and phone number:
1.
2.
3.
4.


(* questions are required)
References Required

Community-based Big Brother/Sister/Couple or Family Volunteers
1 Employer
4 Personal References
*High School Volunteer: Please provide two school staff
*Couples or Family volunteers at least 1 from someone who knows you as a couple.

Site-based Volunteers
1 Employer
3 Personal References
*High School Volunteer: Please provide two school staff.

Personal references should be individuals who know you well (preferably at least two years). Couples references are individuals who know both members of the couple. Complete address needed to mail references. Please, do not list relatives!

Employer Reference (if not employed, please provide one additional personal reference)

Name Home Phone
Address Cell Phone
  Business Phone
City E-mail Address

 

Personal References

Reference #1

Name Home Phone
Address Cell Phone
  Business Phone
City E-mail Address

Reference #2

Name Home Phone
Address Cell Phone
  Business Phone
City E-mail Address

Reference #3

Name Home Phone
Address Cell Phone
  Business Phone
City E-mail Address

Reference #4

Name Home Phone
Address Cell Phone
  Business Phone
City E-mail Address

(Reference #4 NOT required if volutneering for a Site-based program.)
*If Couple or Family reference required, list as reference #4

I understand that a Kansas Bureau of Investigation and/or Police Department and/or other criminal background checks, a child abuse registry check, a motor vehicle check, court diversion check, and sex offender check will be made of my background and that all information about me will be kept confidential by Kansas Big Brothers Big Sisters. My consent to which is hereby given, which consent shall be a continuing consent to periodic record checks for as long as I am matched to a Little Brother or Sister.

I understand that my service as a Kansas Big Brother or Big Sister (KSBBBS) is voluntary and consensual and that I serve at my own risk.  I understand KSBBBS Inc. assumes no liability for my well being and does not provide insurance coverage for injuries I sustain during my service as a Big Brother or Big Sister.  I understand that I am responsible for providing my own insurance, including but not limited to personal liability and automobile insurance and health and accident insurance.

* Questions are required