High School Bigs Application

Statement of Understanding

I understand that by submitting this application I am not obligated, if called upon, to perform the services applied for. Personal information provided here is accurate. The agency is not obligated to match me with a child and can at anytime terminate my application or mentoring relationship. All information gathered is the property of Big Brothers Big Sisters of Northwestern Michigan (Bigs) and only available for review by the Bigs’ team. If I am accepted as a Big, I understand my obligation to meet with my Little regularly and as required, inform the Bigs’ team of the status of my match relationship. I further agree to accept the supervision of the Bigs’ team and discontinue my service if I am requested to do so.

Full Name *

First

Middle

Last

Date of Birth *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Legal Record *

Please list any arrests, convictions, and traffic violations you have incurred. Felony or misdemeanor offenses for a sex-related crime or violence against a person automatically disqualifies an applicant from participation in the program.
If not applicable, please note “N/A” above.

Gender and Pronouns *

Ethnicity

Driver Information

Do you have a drivers license or permit? *

Yes
No

Auto Insurance Company (if applicable)

Auto Insurance Policy Number (if applicable)

Emergency Contact Info

Emergency Contact Person's Name *

Emergency Contact's Relationship to Applicant *

Parent
Legal Guardian

Emergency Contact Person's Phone Number *

School Name *

Graduation Year *

How did you hear about our program? *

Preferred elementary school at which you wish to mentor *

References

Authorization to Contact References: *

References are an important part of the application process. We ask for references from specific people who have known you for a period time. Please let the individuals know that they will be hearing from us via text and/or email as part of your screening for the Bigs program. By initialing above and submitting your application, you authorize the below listed references to disclose information to Bigs regarding your character and/or any past youth-serving experience.

Reference 1

Parent or Legal Guardian

Reference 1: Name *

First

Last

Reference 1: Phone *

Reference 1: Email *

Reference 1: Relationship to Applicant *

Reference 2

Teacher/School Counselor

Reference 2: Name *

First

Last

Reference 2: Phone *

Reference 2: Email *

Reference 2: Relationship to Applicant *

Reference 3 (If Applicable)

Volunteer or paid experience working with children (If you have had any volunteer or paid experience working with youth, you must list the organization(s) and/or individual(s) as a reference. Examples include camp counselor, mission trips or coaching youth. Babysitting does not qualify) Required information: Name of organization, Name of Contact Person, Phone Number, Email and Dates of Involvement.

Reference 3: Name

First

Last

Reference 3: Phone

Reference 3: Email

Dates of Involvement

Parent/Guardian Permission for Teen Volunteer Participation in School-Based Mentoring Program

As a Big in the BBBS School-Based mentoring program, I understand my teen will be expected to adhere to the following rules:
1.) The match with an elementary school student (the Little) is for a minimum of one school year.
2.) All activities between my teen and the Little will take place on school property at a time approved by school personnel that does not remove my child from an academic class.
3.) My teen is not allowed to transport a Little under any circumstances or arrange to see them outside of the school setting.
4.) My child will contact their BBBS Mentoring Specialist immediately if there are any questions or concerns.
5.) I will support my teen’s participation in the BBBS program so that it will be a positive and beneficial experience for both the Big and the Little with whom they are matched.

Parent/Guardian Consent for Participation *

Yes
No

Do you consent to the above for your teen?

Parent/Guardian Consent for Media Release *

Yes
No

I give permission for my child to participate in publicity events, such as radio, television, social media, printed material and news articles regarding the Bigs’ program while they are a Big.

Parent/Guardian Signature *

Clear Signature

Applicant Signature *

Clear Signature

Background Consent Form

Please print the Background Check Consent Form, hand sign and return via email to brooke.stebner@bigsupnorth.com or by mail to:

Big Brothers Big Sisters

c/o Brooke Stebner

900 E. Front Street, Suite 125

Traverse City, MI 49686

NOTE: If you are over 16, you will be required to provide your Social Security number for background check purposes when requested at a later date.

Background Consent Form Confirmation *

It is completed and emailed or hand delivered.
It is completed and will be uploaded below.

I have printed, completed and submitted the Background Consent Form.

Background Consent Form Upload (Optional)

Click or drag a file to this area to upload.

Upload a fully completed and signed consent form here.

Additional Information Required

If you have a Driver’s License or Permit:

Take a photo and email to brooke.stebner@bigsupnorth.com

If you DO NOT have a Driver’s License or Permit:

Take a photo of your School ID and Parent’s Driver’s License and email to brooke.stebner@bigsupnorth.com

Driver's License/Permit photo OR School ID and Parent's Driver's License photo emailed. *

Photo(s) completed and emailed.

Questions

If you have any questions, please contact Brooke Stebner at brooke.stebner@bigsupnorth.com or call/text 231.620.3193.