Volunteer ApplicationApply to be a part of our community! 3 Volunteer Type(Required)Choose OneCommunity BasedSchool or Site BasedMentors PlusUndecidedLegal Name(Required) First Middle Last Preferred Name First Previous Last Name (If Applicable) Last Local PhoneWork PhoneCell Phone(Required)Date of Birth(Required) Month Day Year SSNEmail(Required) Local Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)Gender(Required)Choose OneMaleFemaleWrite InGender (write in)(Required)Marital Status(Required)Choose OneSingleMarriedEthnicity(Required)BackgroundHighest Grade Level Completed(Required)Employer(Required)Occupation (If Student, Where?)(Required)Can We Contact You at Work?(Required)Choose OneYesNoWork Hours(Required)How Long Have You Been Employed?(Required)Is your permanent address different from your local address?(Required)Choose OneYesNoPermanent Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)Name of Spouse (If Applicable) First Last Children Name & Age (If Applicable)List other residences within the past five years (Address & Date)TransportationPossession 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?(Required)Choose OneYesNoState of Issue(Required)License Number(Required)Expiration Date(Required) Month Day Year Do you own or have access to reliable transportation?(Required)Choose OneOwn AutoUse of Someone Else's AutoCopy of Car InsuranceMax. file size: 50 MB.Have your driving privileges ever been suspended or revoked?(Required)Choose OneYesNoIf yes, please explain the offense and length of suspension or revocation.(Required)BackgroundHave you ever been arrested, charged or convicted for a misdemeanor or felony?(Required)Choose OneYesNoIf yes, list below the offense, dates, jurisdiction location and disposition.(Required)Do you currently have any pending court actions?(Required)Choose OneYesNoIf yes, please explain.(Required)Previous ExperienceHave you ever applied before (or have been) to be a Big Brother or Big Sister?(Required)Choose OneYesNoWhen & Where?(Required)What, if any, other youth organizations have you worked for or been involved with as a volunteer?Name of OrganizationCity/StateFrom/ToOffice HeldName of OrganizationCity/StateFrom/ToOffice HeldName of OrganizationCity/StateFrom/ToOffice HeldReferencesPlease list four people you have known for at least one year including your immediate supervisor, past supervisors, professors, and roommate(s) (if applicable), and spouse/significant other as references. 1. Name First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day PhoneEmail 2. Name First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day PhoneEmail 3. Name First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day PhoneEmail Activity ChecklistCheck each activity you either like or think you might want to try.Sports Basketball Boating Swimming Baseball Bowling Biking Volleyball Roller Skating Ice Skating Go Karts Sledding Tennis Football In-Line Skating Weight Lifting Gymnastics Water Skiing Downhill Skiing X-Country Skiing Miniature Golf Other Sports (Other)Arts & Crafts Sewing Drawing Painting Dancing Woodworking Model Building Singing Baking Photography Cooking Other Arts & Crafts (Other)Outdoors Camping Fishing Hunting Gardening Beach Hiking Picnics Other Outdoors (Other)Games Cards Chess Checkers Board Games Video Games Other Games (Other)Science/Mechanics Auto Mechanics Airplanes Chemistry Electronics Computers Musical Instruments Other Science/Mechanics (Other)Additional Movies Sightseeing Concerts Museums Reading Zoos Shopping Plays Other Additional (Other)HobbiesOf all the activities listed above, which 3 would you like to do most?Do you have any pets? What Kind?What things do you collect?What are your favorite TV programs?What clubs/groups do you belong to?PLEASE NOTE: A COPY OF THIS CHECKLIST MAY BE GIVEN TO YOUR LITTLE AT THE INITIAL MATCH (FIRST MEETING).LegalConfidentiality Policy(Required) I agree to the confidentiality policy.I understand that all records of Big Brothers Big Sisters of Northcentral Wisconsin are confidential. Records include, but are not limited to, all application materials, case supervision records and correspondence. The right to confidentiality applies not only to written records but also to video, film, pictures and use of client or volunteer names in agency publications. In order to provide a service that is in the best interest of the children we served by the program, information from outside sources, including confidential references, must be assessed along with information gained from the clients and volunteers themselves. All records, including information from outside sources must be kept confidential and are therefore not available for review by the client or volunteer. Name of Volunteer(Required) First Middle Last Date(Required) Month Day Year Signature of Volunteer(Required)Public Relations Permission(Required) I give my permissionI give my permission for Big Brothers Big Sisters of Northcentral Wisconsin to use my photographs and video publically for promotion and marketing. I understand that the images may be used in print publications, online publications, presentations, websites, public service announcements, and all forms of media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.Name of Volunteer(Required) First Middle Last Date(Required) Month Day Year Signature of Volunteer(Required)Big Brothers Big Sisters retains the right to accept or deny participants or close a match at any time. Should we notify you that you are not accepted as a volunteer Big, you may appeal by: Grievance Procedure: An aggrieved program participant (i.e., applicant, volunteer, parent/guardian of a child, child) should discuss their grievance with their Enrollment and/or Match Support Specialist. If such a step does not bring resolution, the aggrieved party may appeal to the Program Director. If such a step does not bring resolution, the aggrieved party may appeal to the CEO. If a satisfactory conclusion cannot be reached by this point, the aggrieved party can request that their case be reviewed by the Executive Committee of the Board of Directors. The Executive Committee will make its recommendation to the Board of Directors. All decisions of the Board of Directors are final. The information given in this application is correct and accurate to the best of my knowledge. I have reviewed all my responses before forwarding this document to Big Brothers Big Sisters of Northcentral Wisconsin. Further, I understand and agree that as part of the Big Brothers Big Sisters enrollment process, agency personnel will obtain personal information about me from references, public records, interviews, and other sources as deemed necessary for program participation. I understand and agree that as part of the Site-Based mentoring with the Boys and Girls Club of the Wausau area (if applicable), Big Brothers Big Sisters of Northcentral Wisconsin may share feedback and information with the Boys and Girls Club. By signing this application, I hereby release and indemnify Big Brothers Big Sisters of Northcentral Wisconsin, Inc., the Boys and Girls Club of the Wausau area (if applicable), its officers, board of directors, staff, and participants from and against all claims and liability for negligence, willful misconduct, or sexual abuse relating to my participation in this program. Please be advised that under Wisconsin law volunteers are not considered “workers” and therefore are not covered by a workers’ compensation policy. You are advised to check the adequacy of your own personal health coverage before volunteering for Big Brothers Big Sisters of Northcentral Wisconsin. Name of Volunteer(Required) First Middle Last Date(Required) Month Day Year Signature of Volunteer(Required)DonationsThere are many costs associated with becoming a volunteer with our youth serving organization. Please take a moment and consider donating.Would you consider supporting Big Brothers Big Sisters of Northcentral Wisconsin by helping to cover the cost of your enrollment expenses? Yes, I would like to donate $20 to cover the cost of my enrollment Yes, I would like to donate a different amount Donation Amount(Required)Would you like to make this a reoccuring donation?(Required)Choose OneYesNoDonation Type(Required) Venmo @bbbsncw (verification code 3684) Visa Master Card Discover American Express Credit card transactions will be processed on the next business day.Name (as it appears on card)(Required)Credit Card Number(Required)Credit Card Number(Required)Expiration Date(Required)MM/YYCCV(Required)3 digits on back of card, unless American Express then 4 on front)Card Holders Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Credit Card Processing Form(Required) I agree to the credit card processing form.I agree to pay the total amount shown above in compliance with the cardholder’s agreement. If for any reason the transaction is declined, I agree to make other payment arrangements with Big Brothers Big Sisters of Northcentral Wisconsin for the item(s) purchased. Signature(Required)Date(Required) Month Day Year Still Have Questions? Contact Us