Mentor Application

Name*

First Last

Phone Number*

Date of Birth*

Gender Identity*

Preferred Pronoun*

Address*

Street Address Address Line 2 City Province Postal Code

Amount of Time at this Address

How long have you lived in the Area?

Email*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relationship

How did you hear about the program?

Have you ever applied to be, or have been a volunteer with a Big Brothers Big Sisters agency in the past?*

Yes
No

If "Yes", When and Where?

Why do you want to become a volunteer in the program now?*

Employment

Employer

Position

How long have you worked there?

Work Hours

Work Phone

Can we call you at work?

Yes
No

If "Yes", what hours?

Family

Marital Status*

Do you have children?

Yes
No

If "Yes", How many?

Do you see any immediate changes in your life that would affect your ability to be a volunteer?

How does your family feel about you becoming a volunteer with Big Brothers Big Sisters of Central Vancouver Island?

Are you attending school?*

Yes
No

If "Yes", what level and program?

Other

Have you ever been convicted of a criminal offence?*

Yes
No

If "Yes", please explain

Have you ever been accused of, arrested, convicted of, or pardoned of any sexual offense?*

Yes
No

If "Yes", please provide an explanation

References

Personal Reference - Must have known the applicant for at least two years

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Business Phone

Email*

How long have you known this person and in what capacity?*

Vulnerable Sector Reference - If you have not worked with or volunteered with a person or organization responsible for the wellbeing of children or dealt with any other vulnerable population in the last five years, an employment reference is required.

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Business Phone

Email*

How long have you known this person and in what capacity?*

Significant Other - If not applicable, a family reference is required

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Business Phone

Email*

How long have you known this person and in what capacity?*

The information in this form is true to the best of my knowledge.*

Signature (Type Name)**

Date**

Confidentiality Agreement*

I understand the Agency’s policy around confidentiality and have read and agree to all the terms and conditions

All staff and volunteers of Big Brothers Big Sisters of Central Vancouver Island (the “Agency”) are required to abide by this Confidentiality Policy. Any breach of this policy will be considered grounds for termination.

Agency Service Delivery Staff will explain the confidential nature of our service to the volunteer, child and parent/guardian as early as possible in the orientation and/or screening process. At all times thereafter Service Delivery Staff will ensure the privacy of case information.
Information contained in the Casework files will not be disclosed by the Agency to any person without written approval of said person except in the following cases:
1. Where the safety of a child depends upon divulging this information. This could include suspicion of neglect or abuse of a child. The proper authorities will be informed when necessary. This could result in the disclosure of confidential information without written consent from the person to Brothers Big Sisters of Canada’s insurers and or legal counsel, as may be appropriate in connection with any legal proceeding or inquiry;
2. When subpoenaed by the courts;
3. Where required by law; and
4. During periodic agency accreditation reviews; case records, including relevant personal information will be shared to authorized representatives of Big Brothers Big Sisters of Canada.
In the event that confidential information is requested to support a custody or access application, or for any court matter other than a “child protection” case, the Agency will only release the information if required to do so by a Judge’s Order.
No staff member or volunteer shall use confidential information from the agency to advance any personal interest, financial or otherwise.
In accordance with Big Brothers Big Sisters of Canada’s National Standards:
• No information will be provided to persons or organizations outside of Big Brothers Big Sisters of Canada, and its agents, about parents, children or volunteers without their express prior written consent except where required by law.
• All information and records, including electronic records, shall be kept secure (for example, in a filing cabinet, desk, etc. under lock and key, password protected, etc.) and confidential at all times.

Case records will be accessible only to the Caseworker, Executive Director, Casework Supervisor, and in appropriate situations, other Caseworkers.

Staff / Volunteer Code of Conduct*

I understand the Agency’s Code of Conduct and have read and agree to all the terms and conditions.

In the interest of the children and youth that we serve, Big Brothers/Big Sisters staff and/or volunteers commit to improving the life of a child by observing the following code of conduct:

1. You agree to conduct yourself in a manner consistent with your position as a positive role model to a child, and as a representative of the Agency;
2. You will follow Agency policy and guidelines around the safety of the child as outlined in the Agency’s Child Safety Program and not engage in any behavior that may be perceived as being sexual/or abusive with the Child or any member of the Child’s family;
3. You agree to respect the privacy and dignity of the Little/Mentee and family by not divulging confidential information without consent, except where required by law as in the case of suspected child abuse;
4. Staff agree to limit their involvement in a mentor/mentee or parents’ life to what is deemed appropriate by the Agency. Both are seen as an influence, not a dominant factor, in the person’s life;
5. The adult-child/Adult-adult relationship is based on mutual respect. Both agree to treat each other in a respectful way at all times;
6. Staff will allow Volunteers to develop their friendship with their Little/Mentee at their own pace;
7. You are required to discuss problems, issues, concerns, or changes of circumstances (living situation, change of address, phone number etc.) with the Agency contact person;
8. In the event of match closure, both must be sensitive to the impact that this can have on the child, and take the necessary steps to minimize upset to the child. All matches are to be formally closed by the agency caseworker; and
9. You agree to not consume any alcohol or drugs prior to or during any visit with a child.

VOLUNTEER PERMISSION AND RELEASE AGREEMENT*

I agree to the terms and conditions

TO: Big Brothers Big Sisters Central Vancouver Island (THE “AGENCY”)

The Agency and Big Brothers Big Sisters Canada (“BBBSC”) are separate entities and this Agreement is between me and the Agency.
By applying to volunteer with the Agency (“Volunteer Application”) and signing this Agreement, I acknowledge, understand and accept that:

I am a legal resident of Canada and have reached the age of majority in the province or territory in which I reside. I acknowledge and agree that if I have not reached the age of majority of the province or territory in which I reside, my parent or legal guardian will also need to sign this Agreement in order for my Volunteer Application to be considered;

There is no obligation on the Agency to accept my Volunteer Application or assign me as a volunteer into a mentoring program (a “Mentoring Program”) and the Agency may terminate my involvement in a Mentoring Program in its sole discretion and without reason;
If I am accepted as a volunteer, my involvement in a Mentoring Program is not intended to create and shall not be construed as creating either an employee–employer relationship or a contract for services that would allow me to receive a salary, compensation, payment or any benefits, monetary or otherwise; and
If I am accepted into a Mentoring Program, I understand that I will be required to enter into a confidentiality agreement with the Agency, and I agree to abide by the volunteer position description(s) and code(s) of conduct established by the Agency, including any applicable guidelines, Standards and policies.

Assumption of Risk, Release and Reimbursement

I acknowledge, understand and accept that:
I am responsible for all risks associated with my involvement in a Mentoring Program including, without limitation, the risk of bodily or psychological harm or injury;
Subject to local laws, I agree not to sue the Agency, BBBSC and/or any of their member agencies in respect of any such injury or claim resulting from my participation in a Mentoring Program, my Volunteer Application, the acceptance or denial of my Volunteer Application, the Alumni Program and/or my association with the Agency or BBBSC;

I understand that I am fully responsible for any damage to my personal vehicle and/or property during my volunteer involvement in a Mentoring Program and that neither BBBSC nor the Agency insures personal vehicles or property belonging to its volunteers; and
I agree to reimburse the Agency and/or BBBSC and/or any of their member agencies for any damages or losses of any kind (including but not limited to the injury of any other person and/or damage to or loss of property) that may arise in connection with my gross negligence, willful misconduct, or failure to act in accordance with published BBSC policies and guidelines and relating to or arising in connection with my participation in a Mentoring Program or my association with the Agency or BBBSC, including payment of any and all legal expenses of the Agency, BBBSC and/or any of their member agencies.

Background Check

I understand that my acceptance into the Mentoring Program will be conditional on my successful completion of a background check, which may include contacting the references included in my Volunteer Application and/or a criminal record check, for the purposes of confirming my suitability for the Mentoring Program. I agree to provide all necessary consents for such background checks.

Privacy Notice.

The personal information provided by me or otherwise collected by the Agency in connection with my application will be used by the Agency for the purpose of evaluating and considering my Volunteer Application and, if accepted into a Mentoring Program, for the purpose of administering the Mentoring Program. This information may include my name, phone number, mailing address, date of birth, results of background check, and driver’s license and auto insurance information. My personal information will be maintained by the Agency on a confidential basis and will only be disclosed to the parent(s) and/or guardian(s) of a child with whom the Agency may consider “matching” me in a Mentoring Program, to representatives of a school or institution in connection with my participation in a site-based Mentoring Program, to the BBBSC as required for the purposes of accreditation reviews or legal proceedings and as otherwise required or permitted by law. In the event the Agency ceases operations, any and all information about me held by the Agency will be provided to BBBSC, another BBBSC agency selected by BBBSC, or both and will be used for the purposes set out above.

Other Terms of this Agreement

a) In entering into this Agreement, I am not relying on any oral or written representations other than as set forth in this Agreement;
b) This Agreement shall be governed by and construed pursuant to the laws of the Province or Territory in which the Agency is located; and
c) In the event that any provision or term of this Agreement is held to be invalid, illegal or unenforceable, the remaining provisions of this Agreement shall remain in full force and effect.

Media Consent

Any photographs or video productions taken of volunteers by agency staff at recreational events or match outings, or otherwise authorized by the Executive Director or Board of Directors, may be used by the agency for purposes of promotional material including brochures posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners and Big Brothers Big Sisters of Canada for program promotion.

If you do or do not agree with the item "Media Consent" above, Please check here*

I agree
I do not agree

IMPORTANT: I acknowledge that I have read the terms of this Agreement, 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.

Signature of Applicant (Type Name)*

Your Name*

First Middle Last

Date*

Signature of Parent or Legal Guardian, if required (Type Name)

Name

First Middle Last

Date