High School Big Application In addition to this application, a High School Big Parent/Guardian Permission Form must be submitted to participate in this program. "*" indicates required fields Name* First Middle Last Birth Date* MM slash DD slash YYYY Email* Home Address* 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 What county are you in?*Choose your countyAveryBuncombeBurkeCherokeeClayGrahamHaywoodHendersonvilleJacksonMaconMadisonMcDowellMitchellPolkQualla BoundaryRutherfordSwainTransylvaniaYanceyCell Phone*Home Phone*Name of Current School*Student ID Number*This field is hidden when viewing the formStudent ID Number*Employer(if employed)Year in school*Ethnicity*American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteParents Name(s)*Parents Employer(s)*Parents Work Phone*REFERENCESPlease type or print information requested for two references: a teacher or school counselor who knows you well an adult employer, co-worker or friend who has known you for at least 2 years1. School Name*Teacher’s or Counselor’s Name*Phone*Email* 2. Employer, Adult Coworker or Friend:*Phone*Email* Have you ever applied before (or have been) to be a Big Brother or Big Sister?*YesNoIf so, where and when:*What, if any, other youth organizations have you worked for or been involved with as a volunteer?*Consent* I agreeACKNOWLEDGEMENTS I understand that: - The references I listed may be contacted by mail, telephone, or email - I am in no way obligated to perform any volunteer services - 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 - The BBBS agency is not obligated to match me with a youth - As part of the enrollment processes, you will be asked to provide additional personal information prior to make any recommendations for assignment. CONFIDENTIALITY POLICY Big Brothers Big Sisters of WNC respects the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff. All records are considered the property of the agency and not the property of the agency staff, clients, or volunteers. Records are not available for review by the clients or volunteers. 1. Information will be released to non-BBBS organizations or other individuals only with the client’s or volunteer's written consent. 2. Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteer request otherwise. 3. For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies such as Big Brothers Big Sisters of America may have access to client and volunteer records. 4. Members of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors. 5. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena. 6. Information shall be provided to an agency's legal counsel in the event of litigation or potential litigation involving the agency. 7. State law mandates that suspected child abuse or neglect be reported to the Department of Social Services. 8. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities. 9. At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. Information about the volunteer that is shared with the parent/guardian may include such items as: age, sex, race, religion, interests, hobbies, marriage, family status, sexual orientation, living situation, etc. Information about the child that is shared with the volunteer may include age, sex, race, religion, interests, hobbies, family situation, etc. I agree to program participation under the above conditions.Signature*NameThis field is for validation purposes and should be left unchanged. Δ
