Communities In Schools of South Central Texas, Inc.
MENTOR APPLICATION
**Please Print**Date:______
FullLegal Name:______Name I go by: ______
Address:______City/State/Zip: ______
Home phone:(___)______Cell phone: (____)______DOB:______
Email address: ______
EDUCATIONAL BACKGROUND/ Highest level of Education (check one):
____GED ____HS Grad ___ Tech Grad ____SomeCollege ____Bachelor ___Post Bachelor
EMPLOYMENT INFORMATION: (check one): ____ Employed ____ Not Employed ____ Retired
Employer name: ______
Address: ______
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. ______
AVAILABILITY: Please indicate probable days and times you are available to mentor between 8:00 a.m. and 3:30 p.m., especially around the lunch hour:
From To From To From To
Monday ______- ______Wednesday ______- ______Friday ______- ______
Tuesday ______- ______Thursday ______- ______
Do you have any other special skills, interests, or talents that you could share with theCISprogram? Please include speaking or writing in another language and list language and skill level ______
MENTORING INTEREST SURVEY: Grade of student you wish to work with ______
Check all grades you are willing to work with:
____Elementary (Pre-K through 5th) _____ Middle School (6th-8th) _____ High School (9th - 12th)
Circle your campus preference(s):
NEW BRAUNFELS ISDCOMAL ISDSCHERTZ/CIBOLO/UCISD
Oak Run Middle SchoolGoodwin/Frazier ElementaryRose Garden Elementary
New Braunfels MiddleBill Brown ElementaryWiederstein Elementary
New Braunfels HighMorningside ElementarySchertz Elementary
Freiheit Elementary Rose Garden Elementary
MARION ISDStartzville ElementaryWilder Intermediate
Krueger ElementaryRebecca Creek ElementaryDobie Junior High
Marion Middle SchoolClear Spring ElementaryCorbett Junior High
Marion High SchoolCanyon Middle SchoolByron Steele High School
Church Hill Middle SchoolSamuel Clemens High SchoolWiederstein ElementaryChurch
Mountain Valley Middle School
Canyon High School
Clemens High School
REFERENCES: (No Relatives Please)
1.)Name: ______Years known:______
Address, City, Zip:______
Work or personal E-mail: ______
Best Phone :(____)______Secondary #:(____)______
Best time to callbetween 8a – 5pm ______Relationship:______
2.)Name: ______Years known: ______
Address, City, Zip:______
Work or personal E-mail: ______
Best Phone :(____)______Secondary #:(____)______
Best time to call between 8a – 5pm ______Relationship: ______
Please return your application with a copy of your Driver’s License, Authorization for Criminal Background Check, and the DPS Criminal History Verification Form.
By mail:161 S. Castell Ave., New Braunfels, TX 78130
By fax:830-620-5643 ext. 12
Byemail:
Our website is
THANK YOU 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!
ADDITIONAL VOLUNTEER OPPORTUNITIES: If you are interested in receiving informationplease indicate: ___Wurstfest Booth ___Rock-n-Roll for Kids ___CIS thrift store, CommUnity Resale
Communities In Schools of South Central Texas, Inc.
Authorization for Criminal Background Check
I understand that it is a requirement that all employees and volunteers of the Communities In Schools programs in Texas, successfully pass a Criminal Background Check in order to work for or volunteer with this school-based program. By my signature below, I give permission to Communities In Schools of South Central Texas to obtain any history of criminal records I might have. I understand that if there are records as noted below, that I will be unable to work for or volunteer for this CIS program. All records will remain confidential.
Prohibitive records include:
- Any offense under Title 5 of the Texas Penal Code (offenses against the person)
- Any offense under Title 6 of the Texas Penal Code (offenses against the family)
- Any offense under Title 9 of the Texas Penal Code (offenses involving public indecency)
- Any individual who has committed an offense under the Texas Controlled Substance Act, Chapter 481 of the Health & Safety Code within 10 years prior to the date of employment or volunteer status
- Any individual who has committed a felony
- Any individual who has committed a misdemeanor involving moral turpitude within 10 years prior to the date of employment or volunteer status
By signing below, I hereby swear and affirm that I have not been convicted of any of the offenses listed above. I authorize a criminal background check now and at any time in the future that I retain my employment or my volunteer status with Communities In Schools of South Central Texas.
Have you lived outside the State of Texas within the last three years? ____Yes ____No
Full Name (please print) ______DOB ______
Address ______
Signature ______
To be completed by CIS Supervisor only:
I have verified this applicant’s identity by viewing his/her ______. The DOB is ______.
Signature______CBC Approved: ______By: ______
DPS Computerized Criminal History (CCH) Verification
(AGENCY COPY)
I, ,have been notified that a computerized criminal
APPLICANT or EMPLOYEE NAME (Please print)
history (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on
name and DOB information I supply.
Because the name based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization (as listed below)conducting the criminal history check is not allowed to discuss any information obtained using this method, therefore the agency may offer the opportunity to have a fingerprint search performed to clear any misidentification based on the name search, if the search provides a criminal report I know could not be mine.
For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (automated fingerprint identification system). I have been made aware that in order to complete this process I must have the correct fingerprinting (FAST) form from this agency, make an online appointment, submit a full and complete set of my fingerprints, and pay a fee of $24.95 to the fingerprinting services company, L1Enrollment Services.
Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.
(This copy must remain on file by your agency. Required for future DPS Audits)
______
Please:Check and Initial each Applicable Space
CCH Report Printed:
YES / NO / initial
Purpose of CCH:
Hired / Not Hired / initial
Date Printed: / / / initial
Destroyed Date: / initial
Retain in your files
Signature of Applicant or Employee
______
Date
Communities In Schools of South Central Texas
Agency Name (Please print)
Agency Representative Name (Please print)
______
Signature of Agency Representative
Date