HTML Preview Student Mentor Application page number 1.
2011-2012
Dear Klein ISD Volunteer Mentor,
We are delighted that you’ve chosen to be a role model for children through our Klein ISD Volunteer
Mentor Program. Please complete the following in-depth application to let us know you better and
match you with an appropriate student. Please bring the completed application form to the training
session, “How to Be a Successful Student Mentor.”
Name: _____________________ Date________________________
Address:
City: Zip:
Phone: Email:
Profession: Title:
Emergency Contact:
Name Phone Number
Bilingual? Indicate Languages/ Written/ Spoken:
How would you describe your personality? Circle all that apply.
Encouraging Friendly and outgoing Talkative Funny Laid Back
Serious Motivational Life of the Party Reserved Quiet
What do you do in your free time?
Watch Movies/Listen to Music/Play Video Games/Enjoy the Outdoors/ Play Sports/Garden
Read/ Enjoy your Hobby/Other (Please list)
What do you hope to accomplish as a Klein ISD Mentor?
What experiences have you had as a mentor/positive role-model to youth?
______
Which grade level would you like to work with?
____3-5 6-8 _______9-12
Do you want to mentor at a specific campus? __________________________________________
Please prioritize the following criteria you would prefer in a student.
___Same gender ___Same ethnicity ___Similar personal interest’s ___Similar background
___No preference Other:_____________________________
Have you completed a Klein ISD Criminal Background Check?______________
How did you learn about the Klein ISD Volunteer Mentor Program?__________________
As a mentor of Klein ISD, I agree to the policies and expectations of the mentor program as stated in
the KISD Volunteer Mentor Guidebook.
Signature Date