First Name: *

Middle Name:

Last Name: *

Sex: *

• Male
• Female

Address: *

City: *

Zip Code: *

Primary Phone: *

Secondary Phone:

Best Time to Call:

Email Address: *

Ethnicity: *

Birthdate: *

Birthplace: *

Please select program(s) of interest: *

• One-to-One Match Program (1 yr+, 1 day a week, a couple of hours)
• After-School Program (6 mo+, Tues or Wed, 2:30-5:30pm, Watsonville)

How did you hear about the agency? (OR How were you most recently reminded?): *

• GoodTimes advertisement
• Newspaper article/ad
• TV commercial / Movie
• 1-800-Volunteer.org
• VolunteerMatch.org
• Volunteer Center of SC County
• University/College
• Volunteer Center
• Friend/Colleague
• Presentation given @ workplace/sports league
• Google search (mentoring)

Driver's License #:

Do you have access to a car? *

• Yes
• No

Do you have auto insurance? *

• Yes
• No

Name of car insurance company:

Employer: *

Occupation:

Length of Employment:

Work Hours:

Contact at Work:

Do you have children? *

• Yes
• No

Siblings Info (How many & their ages): *

Years of High School:

Years of Trade School:

Years of College:

Do you plan to take classes or return to school? If so, please explain.

How long at Current Address: *

Do you rent or own? *

• Rent
• Own

With whom do you live? *

Do you plan to move?

Please list your previous THREE addresses (in the past 5 years) and the dates at each address:

Name of Current Employer Supervisor (OR Current Professor): *

Phone for Current Employer Supervisor (OR Current Professor) *

Address, City, State, and Zip Code:

Name of Personal Reference #1 (Please Note: References should not be family members or relatives. Thank you!): *

Personal Reference #1 Phone: *

Reference #1 Street Address, City, State, and Zip Code:

Name of Personal Reference #2: *

Reference #2 Phone: *

Reference #2 Street Address, City, State, and Zip Code:

Name of Personal Reference #3: *

Reference #3 Phone: *

Reference #3 Street Address, City, State, and Zip Code:

What specific interests and aspects of yourself would you offer as a volunteer?

Please list present membership in organizations and clubs (include offices held):

Please list your volunteer experience (especially with children):

Have you ever been a Big Brother or Big Sister (or been in a similar program)? If so, what program and where? (Please include name or agency and telephone number):

Previous Employer #1 Name:

Your Position #1:

Dates Employed #1:

Reason for leaving #1:

Previous Employer #2:

Your Position #2:

Dates Employed #2:

Reason for leaving #2:

Previous Employer #3:

Your Position #3:

Dates Employed #3:

Reason for leaving #3:

Previous Employer #4:

Your position #4:

Dates Employed #4:

Reason for leaving #4:

Are you planning any change in occupation (place of employment, promotion, etc) within the next year? If so, please explain: *

List three things you like about yourself: *

List three things you would like to change about yourself: *

What appeals to you most about becoming a Big Brother or Big Sister: *

What apprehensions or hesitations do you have concerning this commitment? *

Please indicate your language of preference: *

Please list other languages you are fluent in:

Do you use social networking sites such as blogs, myspace or facebook? *

• yes
• no