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Mentor application approval is based on the results of a criminal background check performed using the information you provide below. Approved mentors are subject to the same rules and regulations as other school volunteers.

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* 1. I am applying to mentor for

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* 2. Campus(es)

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* 3. Applicant's First Name

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* 4. Applicant's Last Name

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* 5. Middle Name

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* 6. Date of Birth

Date

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* 7. Other names used (if applicable):

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* 8. Drivers License or Government Issued ID Number

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* 9. State Issued

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* 10. Street Address

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* 11. City

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* 12. State

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* 13. Zip/Postal Code

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* 14. Email Address

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* 15. Primary Phone Number

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* 16. Secondary Phone Number

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* 17. Have you ever been charged, plead guilty, or convicted of a felony?

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* 18. If yes, please describe

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* 19. Spouse Name (If Spouse is an Advantage Academy Employee)

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* 20. Times of Mentor Availability

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* 21. Preferred Days (Check all that apply)

STATEMENT OF ACCEPTANCE AND AUTHORIZATION

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* 22. I have carefully read and understand this application and authorization. By selecting YES below, I certify the information I provided on this application is true and correct to the best of my knowledge. I understand that any information found to be intentionally withheld or fraudulent, will result in a denial of my application. I agree that this application and authorization in original, faxed, photocopied or electronic form will be valid for any reports that may be requested by or on behalf of Advantage Academy. I understand that the criminal history information obtained by Advantage Academy and its representatives will not be released or disclosed to any person(s) and that such record(s) will be considered CONFIDENTIAL. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application will not be processed further.

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* 23. Signature (type full name)

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* 24. Date

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Mentor activities and duties shall be at the discretion and direction of Campus Administration with proper notification. Advantage Academy reserves the right to decline the Mentor activities, participation, or services of anyone for any reason without cause or notice.

By clicking the SUBMIT button below, I hereby consent and authorize Advantage Academy, its designated agents, and representatives to conduct a comprehensive review of my background and for an investigative report to be obtained for the purposes of evaluating whether I qualify for the school volunteer role for which I am applying. I understand that the scope of the review may include, but is not limited to the following areas: verification of social security number; current and previous residences; civil and criminal history records from any criminal justice agency in any or all federal, state, or county jurisdictions.

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* 25. In order to receive approval, please attach a photo copy of your drivers license or government issued ID.

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Please continue to the following page. The following page is a TX DPS CCH Verification form which authorizes Advantage Academy to perform a criminal history background check. The CCH form is required by state law and is required to process your application.

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