Brilliant Book Clubs, L.L.C. Volunteer Application
2018-2019 School Year

Thank you for your interest in becoming a Brilliant Book Clubs, L.L.C. volunteer! In caring for and protecting the children served by our program, we believe it is our responsibility to seek volunteers that are willing and able to provide healthy, safe, and nurturing relationships to those children. In furtherance thereof, please answer the following questions to the best of your ability. Your answers are confidential and will not be shared.

First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Home Address *
Your answer
Email Address? *
Your answer
Phone Number? (cell preferred) *
Your answer
What is your gender? *
Do you have a preference of school placement? If so, please specify. *
Your answer
How did you hear about the program? (Business, church name, publication, etc.) *
Your answer
Have you previously or do you currently use any of the following substances: *
Required
If your answer is anything other than "No," please explain.
Your answer
Has anyone ever suggested that you may have a substance abuse problem with any of the above? *
If your answer is anything other than "No," please explain.
Your answer
Have you ever been accused, charged with, or alleged to have committed any act of neglecting, abusing, or molesting a child? *
If your answer is anything other than "No," please explain.
Your answer
Have you ever been the subject of any disciplinary action, transfer, or dismissal, as a result of an accident or mishap involving a child? *
If your answer is anything other than "No," please explain.
Your answer
Have you ever been a victim of child abuse or domestic violence? *
If your answer is anything other than "No," please explain what treatment, programs, or other available resources you have accessed to help deal with such abuse.
Your answer
Have you ever been subject to any disciplinary action (including discharge) or investigation by a church, religious, or other organization, or by an employer? *
If your answer is anything other than "No," please explain.
Your answer
Are you currently taking prescribed medication or self-medicating for any emotional stress or disorders? *
If your answer is anything other than "No," please explain.
Your answer
In the past 6 months, have you been hospitalized due to mental or emotional stress or a related disorder? *
If your answer is anything other than "No," please explain.
Your answer
Is there anything we should know that might hinder your ability to be a great book buddy? *
If your answer is anything other than "No," please explain.
Your answer
Please list two references not related to you that you have known for at least 1 year. *
*Please provide both phone number and email for each reference.
Your answer
Are you interested in other volunteer opportunities other than being a book buddy? *
Training Video Commitment: *
By checking this box, you are agreeing to watch the provided 30-minute training video, and to abide by the instructions and guidelines contained therein. (The video will be e-mailed to you upon submission of this form and must be viewed prior to any placement within a school district.)
Required
VOLUNTEER COMMITMENT AGREEMENT: *
By checking this box, you are stating that you understand the importance of consistently meeting with your book buddies, and that frequent absences can actually do more harm than good for a student's development and emotional well-being. You further understand the advantages of switching days of the week, rather than canceling, if some scheduling conflict arises. Finally, you whole-heartedly commit to doing your very best to meet with your book buddies on a weekly basis, even if it means rescheduling to a different day than normal. If you must miss a few weeks for work or vacation, you commit to communicating clearly and in advance with both your book buddies and their teachers
Required
VOLUNTEER STATEMENT: *
By checking this box, you are verifying that the above responses are truthful, accurate, and complete. Additionally, you declare that you have not and will not engage in sexual abuse, or a pattern of physical or emotional abuse or neglect of a child. You further attest that if you have been the subject of an allegation, a complaint, disciplinary action or dismissal due to such or related acts, regardless of the outcome of the allegation or following investigation, you have notified Brilliant Book Clubs, L.L.C. to make inquiries into your background and authorize all persons associated with you, including churches, employers, law enforcement agencies, and licensing or social services agencies, to release to Brilliant Book Clubs, L.L.C. or it representatives any relative information contained in their records. By checking this box, you acknowledge your responsibility to report to Child Protective Services any actual or suspected abuse or other inappropriate conduct toward any child. You understand that Brilliant Book Clubs, L.L.C. takes allegations of child abuse seriously, and that abuse in any form will not be tolerated. You further understand that Brilliant Book Clubs, L.L.C. will cooperate with civil authorities in the investigation of any reported abuse.
Required
FINANCIAL GIFT: *
Please consider giving a financial gift to Brilliant Book Clubs, L.L.C. to continue to serve Oklahoma school children at no cost to them or the school districts.
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