volunteerapplication

Preferred Name *

Previous Name *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone Number *

Home Phone Number *

Work Phone Number *

Phone *

relationship *

City *

State *

ZIP code *

May we contact you at work *

Yes No

Length of Employment *

Work Hours *

Highest Level of Education *

Have you lived in Tennessee or Kentucky for the last 3 years *

do you have current or past military experience *

Yes No

Dates of Service *

Branch *

Status *

Character of Separation/Discharge *

Reference Name *

Relationship *

City/State of Residence *

Phone Number *

Years Known *

Reference Name *

Relationship *

City/State of Residence *

Phone Number *

Years Known *

Reference Name *

Relationship *

City/State of Residence *

Phone Number *

Years Known *

COMMUNITY BASED MENTOR PROGRAM (18+) *

This is our signature program, where Bigs and Littles meet in the community 2-4 times each month to participate in social activities, such as going to a movie, sporting event, or simply hanging out. The important part of their activity is the one-to-one time and the consistency of the relationship.

SCHOOL BASED MENTOR PROGRAM (18+) *

This looks much like our Community based program, but instead of meeting in the community, our Bigs and Littles meet for one hour each week at the Little's school during the school day. They work on homework, play games, or venture outside together.

Do you have any concerns about your ability to fulfill the 12 month commitment required of mentors? *

Yes No

If yes, please describe: *

Do you anticipate any significant life changes over the next year or had any in the past year? *

Yes No

If yes, please describe: *

Why do you want to become a volunteer with Big Brothers Big Sisters? *

What interests you about working with children? *

The community based program of BBBS of Clarksville serves children throughout Montgomery, Stewart, Houston, Christian and Trigg counties. What distance from your home/work are you comfortable driving in order to pick up your Little? *

The school based program of BBBS of Clarksville serves children at 3 elementary schools in Clarksville. Which elementary school would be most convenient for you? *

Our hours are Monday-Friday, 8 a.m - 4:30p.m. Are there any days and/or times that generally are available for you to come in to interview with us? *

Are there any personality traits, health factors, or family history events in your Little's life that would make you uncomfortable? *

If other, please describe *

FOR BIG SISTERS ONLY: We tend to have more Big Sisters waiting than Little Sisters but a large group of Little Brothers on the wait list. Due to this backlog, we occasionally will ask if a Little Brother is okay with being matched with a Big Sister. Would you be okay being matched with a Little Brother if the opportunity arose? *

Yes No

Do you have any guns, ammunition, or other weapons in your home? *

Yes No

Do you speak any foreign languages? *

Yes No

If yes, which one? *

Are there any pets or animals that reside in your home or on your property? *

Yes No

If yes, please provide details: *

Are there any people besides yourself living in your household? *

Yes No

Name: *

Age *

Relationship *

Name *

Age *

Relationship *

Name *

Age *

Relationship *

Name *

Age *

Relationship *

Is there anything else you'd like to tell us about yourself or any questions you have? *

Have you ever been convicted of a criminal offense (other than expunged juvenile offense)? *

Yes No

If yes, please provide details: *

Have you had any driving citations and/or moving violations in the past 5 years? *

Yes No

If yes, please describe: *

Have you had any convictions that BBBSC may consider to be in reasonable conflict with the related duties of this volunteer job, including pending criminal charges? *

Yes No

If yes, please describe in full: *

Has a court or state agency ever issued you an order or other final notification stating that you have sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult? *

Yes No

If yes, please describe in full: *

Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for children, juveniles, or vulnerable adults; or have you even given up your contract or license because a government agency was taking action against you for failing to care for children, juveniles, or vulnerable adults? *

Yes No

If yes, please describe in full: *

Are you experiencing any physical or health issues that may interfere with or limit your interactions with your Little? *

Yes No

If yes, please provide details: *

Have you seen a mental health professional within the past 5 years? *

Yes No

Address: *

City/State: *

Zip Code: *

Phone Number: *

Fax Number: *

Email address: *

Do you have a history of drug or alcohol abuse? *

Yes No

If yes, have you been sober for a minimum of 2 years? *

Yes No

Have you used any illegal drugs within the past 2 years? *

Yes No

If other, please list: *

If Other, please list: *

If other, please list: *

Which do you enjoy more? *

Watching activities Doing activities Both

Which do you enjoy more? *

Being indoors Being outdoors Both

Do you feel that you would be successful with a: *

Talkative Little Quiet Little

Are there any other interests or preferences that you would like us to consider? *

BBBS OF CLARKSVILLE

420 Madison Street, Ste. B-4
Clarksville, TN 37040
Phone: (931) 647-1418
Email Us

Big Brothers Big Sisters of Clarksville

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