Communities In Schools of the Heart of Texas
Mentoring Application Checklist
REMINDER: Please write legibly. Fill out all forms completely and in blue or black ink.
Do not use pencil.
NAME: _______________________________________________________DATE:______________________
SCHOOL AND/OR GROUP AFFILIATION (e.g. Baylor Buddies, MCC): _____________________________
Please initial that you have completed the following:
____
Application Form (signed and dated)
____
Criminal History Investigation Form
____
Child Abuse/Neglect Central Registry (signed, dated & notarized; applicant signature date and
notary date should match)
____
DPS Verification Form
____
CIS Criminal History Self-Attestation
____
Copy of Drivers License
____
Copy of Insurance
Please check if applicable:
Don’t drive/need to carpool: _____
Willing to carpool/share a ride: _____
Communities In Schools of the Heart of Texas
425 N. Austin Ave, Suite 1500
Waco, TX 76701
Personal Information: Date ____/_____/____ Daytime Phone #_____________Cell #_______________
Full Name: ____________________________________________________________________________
Local Address: _________________________________________________________________________
Permanent Address:_____________________________________________________________________
Email Address: _______________________________________________ Birth Date_____/_____/______
Volunteer Applicant Information:
Can you meet with a child at least 1 hour per week? ___Yes
___No
Availability: Please indicate which day(s) of the week would be better for you to volunteer and what time(s)
would be most convenient with your schedule. Be as specific as possible with time availability.
Mon._________________________ Tues._____________________ Wed.________________________
Thurs.________________________ Fri._______________________
References: Identify at least 3 people unrelated to you, whom you have known for at least 1 year.
Name
Address & Phone Number
Business
Years Acquainted
Mentee Preference: Please check your preferences, if any.
Age: 4-8_____ 9-12_____ 13-17______
Race: Anglo___ African American___ Hispanic___ Asian___ Indian American___ Other___
Gender: Female___ Male___
Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be
willing to work with.__________________________________________________________________
Please check all hobbies/interests that apply to you:
___Crafts ___Music ___Fishing ___Computers ___Cooking ___Reading ___Art ___Biking ___Camping
___Skating/Rollerblading ___Board Games ___Workout ___Parks ___Shopping ___Movies
Sports/List:________________________________________________________________________
Campus Preferences: (We cannot guarantee your preferences)
Waco I.S.D.
Connally I.S.D.
___Bell’s Hill
___Brook Ave. Elem.
___Cedar Ridge Elem.
___Provident Heights Elem.
___South Waco Elem.
___Waco Charter School
___Cesar Chavez Middle
___G.W. Carver Middle
___Indian Spring Middle
___Waco High School
___University High School
___Connally Elementary
Mexia I.S.D.
___RQ Sims Intermediate
Marlin I.S.D.
___Marlin Elementary
___Marlin Middle
___Marlin High School
West I.S.D.
LaVega I.S.D.
___LaVega Elem.
___LaVega Inter.
___LaVega Jr. High
___LaVega High School
___West Elementary
___West Middle
___West High
List any relevant volunteer involvement:
Month & Year
From:
To:
From:
To:
Name & Address of
Agency or Organization
Volunteer Role &
Responsibilities
Immediate Supervisor
and Phone Number
Skills: Complete all that apply.
Relevant license or
certification (LSW,
ACP, First Aid, Child
care, etc.)
Date Issued
Name of Issuing
Authority
License Number
Special skills or areas of expertise that could enhance your volunteer performance:
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you speak any languages other than English, If so, what language(s): ___________________________
Speak: _______
Write: _______
Both: _______
__________________________________________________________________________________________
Applicant Signature:
Please read the following and indicate your understanding and acceptance by signing.
*I certify that all the information provided by me in connection with my application, whether on this document
or not, is true and complete, and I understand that any misstatement, falsification, or omission of information
may be grounds for refusal to hire, or if hired, termination, and possibly for a referral to law enforcement
authorities.
*I understand that CIS-HOT may check a variety of sources for any criminal history, in accordance with
applicable law.
*I authorize any of the persons or organizations referenced in this application to provide CIS-HOT all
information concerning my previous employment, education, suitability for working with young persons, and
any other information they may have related to me. I waive any claim against and release from liability all such
parties, CIS-HOT, and all those affiliated with any of them, for matters in any way arising out of obtaining,
releasing, or relying on any such information or opinion about me.
*ARBITRATION-In exchange for the opportunity to be considered for employment or retention as a volunteer
by CIS-HOT, I agree that any dispute arising out of this application or subsequent services for or employment
by CIS-HOT, or any other claim made by me against CIS-HOT-to the extent it otherwise would be resolved by
a jury trial at court-instead will be resolved with third-party neutral, binding arbitration in McLennan County,
under the Federal Arbitration Act. If that Act nonetheless does not apply, then under Texas Law. This
agreement is entered into and to be considered performed in McLennan County.
Please sign and date: ___________________________________________________________________