| First Name:*
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| Last Name:*
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| Gender :
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| Address :
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| Apartment # :
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| City
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| State :
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| Zip Code :
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| Borough :
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| E-mail :
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| Date of Birth : *
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| Home Phone :*
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| Cell Phone :
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| How did you hear about BBBS of NYC?:
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What boroughs are you willing to travel to? :
Hold the ctrl key to Select more than one.
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What languages other than English do you speak?:
Hold the ctrl key to Select more than one.
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| What country were you born? :
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| What is the highest level of education you have achieved? :
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| Racial Background :
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| Religious Affiliation :
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| How long have you resided in the NYC Metro area?:
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How often does your personal or job schedule require you
to travel outside of NYC? :
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Are you the parent or legal guardian of any children
under
18 years old? :
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| Marital Status :
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| Do you plan to have any (more) children?
:
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| In what general field do you work? :
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| Which of the following best describes your occupation? :
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| Name of Employer:
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| Employer Address :
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| Employer
City
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| Employer
State
:
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| Employer Zip Code :
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| Work Phone :
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| Can we call you at work? :
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| Days Worked? :
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| Hours Worked? :
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| Income :
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| Emergency Contact Name :
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| Emergency Contact Relationship:
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| Emergency Contact Phone :
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Briefly describe your motivation for
applying to become
a Big Brother or Big Sister. :
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Have you ever applied to be, or have been, a Big Brother or
Big Sister? :
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| Have you ever been charged or convicted of child abuse or
child sexual abuse? :
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Have you ever been charged or convicted of any misdemeanor or
felony in this
state or elsewhere? :
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| Have you ever used methadone, even if prescribed by a
physician? :
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Are you confident you can make the time commitment of at
least 1 year with a
youth on a regularly scheduled basis? :
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If matched, will you be able to meet the requirement of
regular supervision
with a case manager? :
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