At Which School Would You Like to Mentor?

905 West Riverside  Suite 301  Spokane, WA 99201   509.413.1436

FIRST NAME / LAST NAME
MIDDLE NAME / MAIDEN NAME
HOME PHONE / CELLPHONE
BIRTHDATE / EMAIL
STREET ADDRESS / CITY
STATE / ZIP CODE

NOTE: Providing the following information is strictly confidential. It allows us to better assess our community outreach and will not be used in any manner to make decisions or judgments regarding a prospective mentor.

GENDER / Female Male / RACE/ETHNICITY
Have you ever been arrested? No Yes / White, non-Hispanic
African American, non-Hispanic
Hispanic/Latino
Native American
Asian
Pacific Islander
Middle Eastern
Mixed-Ethnicity
Other ______
Have you ever been convicted of a crime?No Yes
Are you aware of any outstanding warrants against you? No Yes
Please list any mental or physical disability that would affect your ability to serve as a mentor in any capacity or special accommodations in our program:

Spokane Public Schools / Cheney Public Schools
John R. Rogers High Logan Elementary
Chase Middle School
Garry Middle School
Shaw Middle School
Grant Elementary
Regal Elementary
Roosevelt Elementary
Sheridan Elementary
Stevens Elementary
Cooper Elementary / Cheney Middle School
Westwood Middle School
Betz Elementary
Salnave Elementary
Snowdon Elementary
Sunset Elementary
Windsor Elementary
Cheney High School

At Which School Would You Like To Mentor?

COMMITMENT

To be a PrimeTime Mentor you are committing to mentor your student at least one hour per week during the school year. Please fill in the available days and times that you are able to mentor.NOTE:Elementary mentoring opportunities only exist during the school lunch period.

Available Start Date:______

Days Available / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / At least one hourper week
Times Available

List any previous volunteer experiences (include name of organization) or experience working with youth:

PURPOSE OF MENTORING

Are you a College/University Student? / No Yes / Name of School
Are you volunteering as part of a Service-Learning course/program? / Yes No
If yes, please provide the following:
Instructor’s Name
Instructor’s Phone # and email
Course Title
Are you mentoring as part of a corporate/organization program? / Yes No
If yes, please provide the name of the corporation or program:

Other Reason ______

How Did You Learn About PrimeTime Mentoring?

Have you received services from Communities In Schools in the past? Yes No

Location of Services Received

This form grants Communities In Schools of Spokane County permission to the information above to the Washington State Patrol and other appropriate agencies for a background check. Background check results will be released to Communities In Schools of Spokane County to adhere to school district policies and satisfy liability insurance requirements. All prospective mentors are asked to complete this form, regardless of sex, race, color, creed or social status.

APPLICANT SIGNATURE / DATE
FOR OFFICE USE ONLY
Background check passed / Yes No / Date Info Entered