Please turn your application at our office at:

1409 19th Street, #204
Lubbock, Texas 79401

With your application:

Please turn a photo in with this application.

(This photo is for your file and will not be returned)

Contact All Your References

Let them know to that we will be calling them on your behalf.

THANK YOU FOR YOUR TIME!

YOUR TIME IS THE GREATEST DONATION!

Involvement Survey

Please tell us about your involvement in the community and on campus. Your answers do not affect your ability to volunteer as a Big Brother/Big Sister. Your answers are greatly appreciated; however, this survey is not a required portion of your application.

For Students:

What student organizations are you involved with? (Greek, Service, Academic, etc.)
Please include officer title, if applicable:

______________________________________________________

All Applicants:

What community organizations are you involved with? (Lions Club, Junior League, Special Olympics, etc.)
Please include officer title, if applicable:

______________________________________________________

What religious organizations are you involved with? (Church name, place of worship, etc.)

_______________________________________________________
_______________________________________________________
_______________________________________________________

VOLUNTEER PRE-ENROLLMENT

First Name:

Middle Name:

Last Name:

Date of Birth:

Home Address:

City:

County:

State:

Zip:

Email:

Home Ph #:

Work Ph #:

Cell Ph #:

Male

Female

Social Security #:

Employer:

Address:

City:

State:

Zip:

Occupation:

Ethnicity:

Marital Status:

Highest Level of Education:

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 and #

Expiration date:

REFERENCES

Please type or print information requested for three references: 1) your current or past employer who has known you for at least 1 year; 2)
a co-worker, friend or neighbor who has known you for at least 2 years; and 3) 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:
Day Phone #:	Fax #:				Email:
2. Coworker or Friend or Neighbor:
Address:		City:				State:	Zip:
Day Phone #:	Fax #:				Email:
3. Spouse/Domestic Partner/Friend:
Address:		City:				State:	Zip:
Day Phone #:	Fax #:				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?
Have you ever been involved before with Big Brothers Big Sisters in a capacity other then a Big? Yes No				Where and When:

I understand that:

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

2) I am in no way obligated to perform any volunteer services;

3) The information I provided may be used to conduct a background check, to include driving records check, criminal background check, and other records where required by local, state, or federal law for volunteers working with youth;

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

5) Other BBBS agencies or youth organizations where I have worked or volunteered may be contacted as references; and,

6) As part of the enrollment processes, I will be asked to provide additional personal information prior to any recommendations for assignment.

Signature_____________________________________________Date_______________________

Big Brothers Big Sisters of Lubbock
Public Relations
Release of Confidentiality

I ________________________________, a volunteer for Big Brothers Big Sisters, give permission to Big Brothers Big Sisters to use my name, photograph, and use the story of my experience as a participant in the program for the purposes of promoting the program. I am fully aware that the pictures and/or video may be available for the public view.

________________________________ _________________________________
Volunteer Signature Date Executive Director Date

Confidentiality Agreement
Big Brothers Big Sisters of Lubbock

The clients and volunteers of Big Brothers Big Sisters have the right to privacy and confidentiality. Please read the paragraph below before signing this form.

I understand as a volunteer of Big Brothers Big Sisters of Lubbock, I am responsible for maintaining the privacy and confidentiality of the clients and volunteers involved in the agency.

I understand and I agree that I will not divulge the identity of any client or volunteer at the agency nor will I discuss or divulge any other information I may hear, see or obtain while involved with the agency and thereafter.

I understand that any breach of this agreement could result in the termination of my participation with Big Brothers Big Sisters of Lubbock.

_____________________________________
Volunteer Signature Date

____________________________________
Executive Director Date

Consent For Criminal Background History Check
Authorization/Waiver/Indemnity
Big Brothers Big Sisters of Lubbock

I HEREBY GIVE MY PERMISSION FOR BIG BROTHERS BIG SISTERS OF LUBBOCK, INC. TO OBTAIN INFORMATION RELATING TO MY CRIMINAL HISTORY RECORD THROUGH THE VOLUNTEER CENTERS OF LUBBOCK AND DALLAS COUNTY. THE CRIMINAL HISTORY RECORD, AS RECEIVED FROM THE REPORTING AGENCIES, MAY INCLUDE ARREST AND CONVICTION DATA AS WELL AS PLEA BARGAINS AND DEFERRED ADJUDICATIONS AND DELINQUENT CONDUCT COMMITTED AS A JUVENILE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED, IN PART, TO DETERMINE MY ELIGIBILITY FOR AN EMPLOYMENT/VOLUNTEER POSITION WITH THIS ORGANIZATION. I ALSO UNDERSTAND THAT AS LONG AS I REMAIN AN EMPLOYEE OR VOLUNTEER HERE, THE CRIMINAL HISTORY RECORDS CHECK MY BE REPEATED AT ANY TIME. I UNDERSTAND THAT I WILL HAVE AN OPPORTUNITY TO REVIEW THE CRIMINAL HISTORY AS RECEIVED BY BIG BROTHERS BIG SISTERS OF LUBBOCK, INC. AND A PROCEDURE IS AVAILABLE FOR CLARIFICATION, IF I DISPUTE THE RECORD THE RECORD AS RECEIVED.

I, THE UNDERSIGNED, DO, FOR MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, HEREBY REMISE, RELEASE AND FOREVER DISCHARGE AND AGREE TO INDEMNIFY THE VOLUNTEER CENTERS OF LUBBOCK AND DALLAS COUNTY AND EACH OF THEIR OFFICERS, DIRECTORS, EMPLOYEES, AND AGENTS AND HOLD THEM HARMLESS FROM AND AGAINST ANY ALL CAUSES OF ACTIONS, SUITS, LIABILITIES, COSTS DEBT AND SUMS OF MONEY, CLAIMS AND DEMANDS WHATSOEVER (INCLUDING CLAIMS FOR THE NEGLIGENCE, GROSS NEGLIGENCE, AND/OR STRICT LIABILITY OF THE VOLUNTEER CENTERS OF LUBBOCK AND DALLAS COUNTY), AND ANY AND ALL RELATED ATTORNEYS' FEES, COURT COSTS, AND OTHER EXPENSES RESULTING FROM THE INVESTIGATION OF MY BACKGROUND IN CONNECTION WITH MY APPLICATION TO BECOME A VOLUNTEER/STAFF MEMBER.

______________________________________________________________________
APPLICANT'S SIGNATURE DATE

____________________________________________
PLEASE PRINT FULL NAME

____________________________________________
PLEASE LIST MAIDEN NAME OR OTHER NAME USED

____________________________________
DATE OF BIRTH

____________________________________
SOCIAL SECURITY NUMBER

____________________________________
ETHNICITY

AUTOMOTIVE LIABILITY INSURANCE GUARANTEE

AS A VOLUNTEER OF BIG BROTHERS BIG SISTERS OF LUBBOCK, INC., I UNDERSTAND THAT I AM REQUIRED TO HAVE MY OWN PERSONAL AUTOMOBILE LIABILITY INSURANCE.

I UNDERSTAND THAT BIG BROTHERS BIG SISTERS OF LUBBOCK, INC., DOES NOT INSURE ME AND IS NOT LIABLE IF ANY ACCIDENT SHOULD OCCUR.

_____________________________________________
VOLUNTEER SIGNATURE DATE