Communities In Schools of South Central Texas, Inc.

MENTOR APPLICATION

Please Print:

Date:_________Full Legal Name: ____________________________________________
Addresss:_______________________________City/State/Zip: _______________________
Home phone:(___)_____________ Cell phone: (____)____________ SSN#: ____________
DL#:_________________State:______________________DOB: _____________________
Email address: _____________________________________________________________

EDUCATIONAL BACKGROUND:

Highest level of Education (check one):
____GED____HS Grad ___ Tech Grad ____SomeCollege ____College Grad ___Post Bachelor's

EMPLOYMENT INFORMATION:

(if employed, or past employer if retired)
Employer name and adddress: ____________________________________________________
_________________________________________________________________________________
Work phone & extension:_______________Your Position or Title: __________________
May you be contacted at work? __________

If you have been employed by your present employer for less than one year, please give the name and address of the company you previously worked for: ____________________________________________________________________________________________________________________________________________________________________

MENTOR/VOLUNTEER HISTORY:

Have you ever been a mentor or volunteered with children? ____________ If so, where? __________________________________________________________________________________

What did you enjoy most about your mentoring or volunteer experiences? ____________________________________________________________________________________________________________________________________________________________________
Please share why you want to be a mentor for CIS. ____________________________________________________________________________________________________________________________________________________________________

ADDITIONAL VOLUNTEER OPPORTUNITIES:

If you are interested in receiving information about helping with any of the following activities, please indicate:
___Wurstfest Booth (10/30-11/8/2009)
___Christmas in Gruene/Cowboy Kringle Kids Workshop (first two week-ends in December, 2009)
___Rock-n-Roll for Kids (3/12 set up and/or 3/13/2010 event)
___Pack the Bus (8/6/2010)
___Sort incoming donations to CIS Thrift Store (open 10-6 Tues. thru Sat.)
Please indicate probable days/times you're available to mentor between 8:00 a.m. and 3:30 p.m. (especially around the lunch hour):
From To From To
Monday ________ ______ Thursday _______ _______
Tuesday ________ ______ Friday _______ _______
Wednesday ________ ______

Do you have any other special skills, interests, or talents that you could share with the CIS program? (Including speaking or writing in another language. Please list language and skill level). ______________________________________________________________________________________________________________________________________________________
Do you prefer to work with any specific grade levels? Check all you could agree to work with.
_______ Elementary (Pre-K through 5th) __________Middle School (6th-8th)
________ High School (9th - 12th)

Do you prefer to work at a specific campus? _______ (If yes, circle your preferences).

REFERENCES:

(no spouses please)
1.)Name: ____________________________________________ Years known: _________
Address:__________________________________________________________________
Best Phone Number to reach reference:(____)___________Secondary #:( )_________
Best time to call b/w 8 and 5____________ Relationship: ___________________

2.)Name: ____________________________________________ Years known: _________
Address:__________________________________________________________________
Best Phone Number to reach reference:(____)___________Secondary #:( )_________
Best time to call b/w 8 and 5____________ Relationship: ___________________

THANK YOU so much for your interest in mentoring with CIS of South Central Texas, Inc.
The information you supplied will help us continue to sustain and grow the mentoring program of Communities in Schools. We look forward to adding you to the CIS family.

I hereby authorize Communities In Schools of South Central Texas, Inc. to conduct a criminal background check on me as required by the CIS policies.

Signature of Applicant: _________________________ Date: ______________________

Please return your application with Authorization for Criminal Background Check, Waiver of Confidentiality and Confidentiality Statement by mail to 161 S. Castell Ave., New Braunfels, TX 78130; by fax (830-620-5643); or by email (M'Lissa@cissouthcentraltexas.org).

Thanks!