Communities In Schools of South Central Texas, Inc.
RETURNING MENTOR UPDATES for school year _____________
**Please Print**
Date: __________________________________
Full Legal Name:_________________________________________________ Name I go by: ______________________________
Address: ___________________________________________________City/State/Zip: _____________________________________
Home phone: (___)___________________________ Cell phone: (____)_______________________ DOB:___________________
Email address: ___________________________________________________________________________________________________
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 __________ - __________
LAST YEAR MENTEE INFORMATION:
Last years campus _______________________________
Last years mentee: ___________________________________
Do you wish to continue with this student? _____ If not, 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 ISD
COMAL ISD
SCHERTZ/CIBOLO/UCISD
Oak Run Middle School
Goodwin/Frazier Elementary
Rose Garden Elementary
New Braunfels Middle
Bill Brown Elementary
Wiederstein Elementary
New Braunfels High
Morningside Elementary
Schertz Elementary
Freiheit Elementary
Rose Garden Elementary
MARION ISD
Startzville Elementary
Wilder Intermediate
Krueger Elementary
Rebecca Creek Elementary
Dobie Junior High
Marion Middle School
Clear Spring Elementary
Corbett Junior High
Marion High School
Canyon Middle School
Byron Steele High School
Church Hill Middle School
Samuel Clemens High School
Mountain Valley Middle School
Canyon High School
THANK YOU for your continued support of students! We are so happy to have you as part of our CIS of
South Central Texas Family. The information you supplied will help us continue to sustain and grow
the mentoring program of Communities In Schools. Please return your application with Authorization
for Criminal Background Check, the DPS Computerized Criminal History Verification, and a copy
of your Driver’s License, * REMINDER: The state requires a background check each school year*
By mail:
By fax:
161 S. Castell Ave., New Braunfels, TX 78130
830-620-5643
By email: schapa@cissouthcentraltexas.org
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
Full Name (please print) __________________________________________________
____No
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)
___________________________________
Signature of Applicant or Employee
_________________
Date
Communities In Schools of South Central Texas
Agency Name (Please print)
Please:
Check and Initial each Applicable Space
CCH Report Printed:
YES
___________________________________
Signature of Agency Representative
Date
initial
Purpose of CCH:
Hire
Agency Representative Name (Please print)
NO
Not Hired
initial
d
Date Printed:
initial
/
Destroyed Date:
initial
Retain in your files