Mentor Application – Virtual ISM Mentor Application – Virtual ISM Legal Name(Required) First Last Preferred Name Date of Birth(Required) MM slash DD slash YYYY Gender Identity(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Country Primary Phone(Required)Secondary PhoneEmail(Required) How did you learn about the Big Brothers Big Sisters Program?Have you ever been, or applied to be, a volunteer with a Big Brothers Big Sisters agency in the past?(Required) Yes No If yes, when and where? Are you currently employed?(Required) Yes No If yes, who is your employer? Are you currently attending school?(Required) Yes No If yes, which school do you attend? What is your field of study? Daytime Availability?(Required) Yes No Vulnerable Sector ReferenceIf you have worked or volunteered with vulnerable people (children, elderly, people with disabilities etc.) in the past 5 years, please provide us with a reference of someone who supervised you during this time (this must be someone who supervised you and CANNOT be a family member). If you have NOT worked or volunteered within a vulnerable sector in the past 5 years, please provide an employment or volunteer reference (this must be someone who supervised you and CANNOT be a family member). Reference Name(Required) First Last Relationship to Yourself(Required) Email(Required) Phone(Required)Current City of Residence(Required) Organization Name(Required) Role at Organization(Required) I confirm that the reference above is someone I directly reported to and is not a family member.(Required) Yes Significant Other ReferenceIf you do not have a significant other, please leave blank, and provide us with a family reference. A significant other reference is someone you view currently as a significant part of your life who has known you for at least 2-years. This could be someone you are dating, living together with, a common-law partner, or married to. Reference Name First Last Relationship to Yourself Email PhoneCurrent City of Residence I confirm that if I have a significant other at present time, I’ve provided them as a reference.(Required) Yes Family ReferenceReference Name(Required) First Last Relationship to Yourself(Required) Email(Required) Phone(Required)Current City of Residence(Required) I confirm that the reference provided above is a family member.(Required) Yes Personal ReferenceThis should be a friend, co-worker, or neighbour you have known for at least 2 years. Please note, this cannot be a family member. Reference Name(Required) First Last Relationship to Yourself(Required) Email(Required) Phone(Required)Current City of Residence(Required) I confirm the reference provided above is not a family member.(Required) Yes Informed ConsentThe above references are aware that they will be contacted.(Required) Yes I consent to Big Brothers Big Sisters of Waterloo Region 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.(Required) Yes I consent to Big Brothers Big Sisters of Waterloo Region 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 involved.(Required) Yes TO 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 EXCEPT WHERE REQUIRED BY LAW. I UNDERSTAND THAT THIS APPLICATION BECOMES THE PROPERTY OF (AGENCY NAME ) AND SUBSEQUENTLY BIG BROTHERS BIG SISTERS OF CANADA.(Required) Yes PhoneThis field is for validation purposes and should be left unchanged. Facebook Twitter Google+ LinkedIn
