Big Brothers BIg Sisters Renewal Application

4196 Herschel St Jacksonville, Florida 32210 800-340-4729 904-387-9798 maryw@jlkirby.com

Big Brothers Big Sisters Renewal Application

Thank you for completing this application. It is being returned to John L Kirby & Associates for immediate processing so we may provide your quote. Your progress will be saved at any point, to complete the application at a later time you must restart from the same computer using the same browser. Your data will be saved for a maximum of 5 days. If you have any questions concerning this application, please call us for help.

Agency Name *

Address *

Address 2

City *

State *

Zip *

Contact Person *

Email *

FEIN *

Annual operating budget

Annual Payroll

Has there been any change in your operation during the past year? *

Yes No

If Yes, please describe changes in operation or programs.

Please indicate the number of matches:

Total Site or School Based Matches *

Community Based Matches:

Community Male: *

Community Female *

Community Couples *

Percentage of matches included in above:

Children of Promised/Amachi Program

Hispanic Mentoring:

Does the affiliate agency adhere to the Big Brothers Big Sisters Standards of Practice for:

One-To-One Service in its completeness

yes no

If no, please explain: *

AGENCY STAFF Indicate the number of staff, contracted professionals, and volunteers:

Any Medical Professionals?

Yes No

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

Any Social Workers?

Yes No

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

Any Clerical / Administrative?

Yes No

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

Any Other?

Yes No

Please describe

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

If contracted professionals are used, does the affiliate agency require them to sign a hold harmless or indemnification agreement?

Yes No

Are Certificates of Insurance required and kept on file for those contracted professionals?

Yes No

Are you aware of ANY claims, allegations, and/or incidence (including abuse & molestation) made against your organization, or against anyone working on your behalf that may give rise to a claim?

Yes No

If yes, please describe. *

Fundraising Events

Description of event

Descripition of event

Date

Number days

Number of attendance

Est. revenues

Alcohol Served

Yes No

Liquor license by BBBS

Add another event ?

Yes No

Description of event

Descripition of event

Date

Number days

Number of attendance

Est. revenues

Alcohol Served

Yes No

Liquor license by BBBS

Add another event ?

Yes No

Description of event

Descripition of event

Date

Number days

Number of attendance

Est. revenues

Alcohol Served

Yes No

Liquor license by BBBS

Add another event ?

Yes No

Description of event

Descripition of event

Date

Number days

Number of attendance

Est. revenues

Alcohol Served

Yes No

Liquor license by BBBS

Add another event ?

Yes No

Description of event

Descripition of event

Date

Number days

Number of attendance

Est. revenues

Alcohol Served

Yes No

Liquor license by BBBS

Add another event ?

Yes No

Description of event

DECLARATION AND SIGNATURE

The person named herein is authorized and designated to give and receive all notices on behalf of the entity and all Insured"s from the entity or their authorized representative(s) concerning insurance.

First Name

Last Name

Title / Position:

The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating the probability of a claim or legal action now known to any entity official or employee has been declared, and is agreed by all concerned that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of this application does not bind or offer any insurance, nor commit the authorized signer to accept insurance, but it is agreed that this application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy should the policy be issued.

Signature of Authorized Entity Representative:

Date Signed

Date