General Information

 

Full Name __________________________________________ Sex  M    F

Phone___________________ Email_____________________ Date of Birth ____________

School Address _______________________________________________________________

Permanent Address ____________________________________________________________

Year in School:    First-Year    Sophomore    Junior    Senior    Graduate

Student Field of Study: Major/s_________________________ Minor_____________________

Applying to be a:    College Buddy    Associate Member

Were you matched as a College Buddy before ?    Yes    No

If yes, name of buddy:______________________________________

If possible, do you want the same Buddy?    Yes    No

Are you interested in taking on a leadership role in your chapter?    Yes    No

If yes, which one(s)?    Membership Coordinator   Activities Coordinator   Treasurer     eBuddies Coordinator

Previous volunteer experience: ___________________________________________________

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Previous experience with mentally retarded persons: _________________________________

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Organizations and Club Memberships (including leadership roles): ________________________

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Other Languages: ________________________________________________________________

Please shade in the times that you are NOT available to meet with your Buddy or attend chapter activities:

	9:00AM	10:00AM	11:00AM	12:00AM	1:00PM	2:00PM	3:00PM	4:00PM	5:00PM	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

 

The best days and times for chapter officers to reach you are: ____________________________

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If matched, the best time for your Best Buddy to call you would be : _________________________

Considering your schedule, do you feel that you can make the time commitment to your Best Buddy?

                    YES       NO

Do you have a car?     YES       NO    If yes, please attach a copy of your insurance.

If yes, would you be willing to transport other Buddy pairs on occasion?    YES     NO

If yes, are you willing to use your car to meet with your Buddy?          YES     NO

Please describe yourself in three words: 1._____________ 2. _____________ 3. _____________

Please check the activities that you most enjoy:

___Watch Movies	___Watch Movies	___Cook
___Play Cards	___Talk on the phone	___Sail
___Travel	___Play computer games	___Take long walks
___Listen to Music	___Play Sports	___Paint
___Write Letters	___Watch Sports	___Roller Skate
___Arts/Crafts	___Do puzzles	___Go to ball games
___Jog	___Dance	___Watch TV
___Bowl	___Ice Skate	___Fish
___Shop	___Cook	___Fix cars
___Sew	___Sing	Other__________________

 

Below please list examples of activities that you like to do. Be specific (i.e. ­ Sports = Basketball, Baseball; Dancing = Swing):

 

 

 

Describe a friendship that you have been involved in and what you gained from it. Also, indicate why you would likethe experience of becoming a College Buddy.

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Best Buddies Pledge and Release

Please initial each statement to show you have read and fully understand your commitment

______ I understand the mission of Best Buddies is to enhance the lives of people with mental retardation by providing opportunities for one-to-one friendships and integrated employment.

______ Dedication is vital to the success of my Best Buddies friendship. I understand that all persons have human rights and must be treated with respect and dignity.

______ I understand that any information released to me about my Buddy is to remain confidential.

______ My signature gives permission for me to be photographed or filmed at Best Buddies events and for photos or footage to be used by the media.

______ I will see my Buddy twice a month, make contact once a week and attend all Chapter Meetings.

 

Signature_____________________________________________ Date____________