Volunteer Registration Form Volunteer Full Application Form Volunteer's InformationProgram of Interest(Required) Big Brother / Big Sister (Community Based) Couples Matching In-School Mentoring Group-Based Mentoring (Go Girls / Game On) Co-op Student Other Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Pronouns Phone(Required)Email(Required) Choose the township where you reside(Required)OrangevilleShelburneErin / HillsburghCaledon VillageGrand Valley / AmaranthMansfield / MulmurMelanchthon / DundalkMonoTottenham / BeetonOtherIf you have chosen "Other" as your answer above please be aware that our office only serves the listed communities. You may be better served at one of our other agencies. Please give a call into the office if you have any questions 519-941-6431 I would like to continue Address(Required) Street Address Address Line 2 City Province Postal Code How long at current address6 months - 1 year1 - 3 years3 - 5 years7 - 9 yearsOver 10 yearsPrevious Address if less than one year Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Do you own or have access to a vehicle?(Required) Yes No If yes, Driver's License Number(Required) Does your car have passenger side airbags? Yes No What is the level of your automobile insurance coverage? Current Employer(Required)If not employed please write N/AEmployerPositionPhone Add RemoveMarital Status(Required) Single Dating Married Separated Divorced Common-law Widowed Partner's Name First Last ChildrenPlease provide the name and ages of any children who live in the home with you.NameAge Add RemoveWhat changes in your family status do you anticipate in the coming year?(Required)How does your partner feel about you becoming a volunteer with Big Brothers & Big Sisters? Education Level(Required) High School Trade School College University Name of Last School Attended:(Required) Current school if presently a student: Have you ever been in trouble with the Police?(Required) Yes No If yes, please explain and provide datesHave you ever been accused, arrested, convicted or pardoned of a sexual offense involving a child or children?(Required) Yes No If yes, please specifyHave you ever been, or applied to be a volunteer with a Big Brother/Big Sister agency in the past?(Required) Yes No If yes, where and when? Are you a member of any other clubs, affiliations or organizations? If so, please list them.What are your interests, hobbies or activities?(Required)How long have you been thinking about becoming a volunteer with this agency?(Required) Less than 4 weeks Less than 3 months Less than 6 months 6 months to 1 year Over 1 year 2+ years How did you hear about this program? TV Current Volunteers Billboard / Bus Shelter Radio Special Event Former Little Newspaper Friend / Relative Website I've always known Why do you want to become a volunteer in the program now?(Required)If you have a preference for a child in a particular age range, please rank your preference OR put the option 'no preference' at the TOP of the list6-1011-1314-16No preferenceReferencesPlease provide contact information for the following references. All references must be over the age of 18. Personal ReferenceThis should be someone you have known for at least two years who can speak to the kind of person you are.Name(Required) First Last Phone Number(Required)Email(Required) Address(Required) Street Address City How long have you known this person?(Required) Relationship to you(Required) Experiential ReferenceThis should be someone you have known for at least two years who can speak to the kind of person you are.Do you have experience working with, or volunteering with vulnerable populations?(Required) Yes No Employment / Volunteer ReferenceThis should be an employer or volunteer supervisor. This reference is only for those who do not have experience working with vulnerable personsName(Required) First Last Phone Number(Required)Email(Required) Address(Required) Street Address City How long have you known this person?(Required) Relationship to you(Required) Vulnerable Sector ReferenceThis should be who supervised or employed you in your work or volunteering with vulnerable personsName(Required) First Last Phone Number(Required)Email(Required) Address(Required) Street Address City How long have you known this person?(Required) Relationship to you(Required) Family ReferenceDo you have someone in your life that you consider to be your partner or significant other?(Required) Yes No Partner / Significant Other ReferenceName(Required) First Last Phone Number(Required)Email(Required) Address(Required) Street Address City How long have you known this person?(Required) Relationship to you(Required) Family ReferenceName(Required) First Last Phone Number(Required)Email(Required) Address(Required) Street Address City How long have you known this person?(Required) Relationship to you(Required) PermissionTo the best of my knowledge, the above information is complete and accurate. I understand that the information contained in this application will be held in strict confidence and will only be used to assess my suitability as a volunteer expect where required by law. I understand that this application becomes the property of Big Brothers Big Sisters of Dufferin and District and subsequently Big Brothers Big Sisters of Canada. I consent to Big Brothers Big Sisters of Dufferin and District contacting the references, in confidence, included in my Volunteer application and I hereby waive the right to request disclosure of the personal references given about me. I consent to Big Brothers Big Sisters of Dufferin and District collecting information from any Big Brothers Big Sisters agency with which I am, or was formerly involved, including a Big Brothers Big Sisters agency in another country with which I am, or was formerly involvedSignature(Required)ImportantConsent(Required)By checking this box, I acknowledge that I have read the Volunteer Permission and Release Agreement as well as the Volunteer Code of Conduct (accessed through the button below), have been given an opportunity to obtain independent legal advice, and understand that it represents a waiver of certain of my legal rights, including my right to sue (subject to local laws). I further agree that such limits are reasonable and sign this Agreement freely, voluntarily and without duress. Media ConsentBy checking this box, I do NOT AGREE with item #6 Media Consent found in the Permission and Release document EmailThis field is for validation purposes and should be left unchanged. Permission and ReleaseVolunteer Code of Conduct bigbrosbigsisofdufferin
