1) * Have you lived in Lancaster County for at least 6 months- Yes No 

2) * Are you able to commit to a year of meeting  2 times a month with a child in your area?  Yes    No                      

3) * Are you over 20 yrs?  If not, are you at least a Junior or Senior in high school or actively attending in post high school training or college in Lancaster County?  Yes   No 

If you have answered YES to all of the above questions, then begin to complete the form below.  If you have answered NO, please contact a Big Brothers Big Sisters and speak to a representative at (717) 397-7567 before taking the time to complete this form. 

* First Name    * Last Name  

* Home Address 

* City   Zip     Cell Phone   

Day Phone     Evening Phone

   *  Please call me at-   Day     Evening     Cell

*  Email Address 

This email is my-    Home    Work 

* Date of Birth       Race  Please Answer Other Caucasion African American Asian Hispanic Pacific Islander Native American Multi-Racial    * Sex  Male Female   

Marital Status   Please Answer Single (never married) Married Divorced/Seperated Living with partner Widowed

Education Level  Please Answer Some High School High School/GED High School + (technical training) Some College Associates Degree Bachelors Degree Masters Degree Professional Degree (ie- PhD, Law, Medical)

* Current Employer   (if retired, please note)

Can you be contacted at work?  Yes     No

*  How did you hear about the Big Brothers Big Sisters program? (please be as specific as possible so we can learn more about how to reach more potential volunteers)