Everybody Wins! Iowa
Literacy and Mentoring Program
Volunteer Information Form
__________________________________________ ________________ ___________
Name SS # * Date of Birth
__________________________ __________ ____ _________________________
Home Address City Zip Home Telephone Number
__________________________________________ __________________________
Business/Organization Name Work / Cell Telephone Number
___________________________________________ __________________________
Business Address Email Address
Is there a preferred day of the week or time that would be best for you? ___________________________
Is there a school where you would prefer to volunteer? (See attached list) ______________________
Efficient in additional language (Spanish) ? _________________________________
Have you every been listed on the sex offender registry: Yes _______________ No ________________
If so, please explain:
Have you ever been named in a founded case of child abuse or is there a current child abuse case pending against you? Yes _______________ No ____________________ If so, please explain:
Have you ever had a certificate or license revoked or suspended: Yes ________________ No ____________
If so, please explain:
I promise that the information I have provided on this form is current and true to the best of my knowledge. I authorize Everybody Wins! Iowa to investigate my background and I agree to cooperate in any such investigation. I authorize and release from liability any third person(s) who provide Everybody Wins! Iowa with any information, including their opinions, regarding my character and fitness for school volunteer activities.
___________________________________________ ___________________________
Signature Date
Please return to: Everybody Wins! Iowa PO Box 691 Des Moines, IA 50303. Fax: 515.274.1537.
Email: everybodywinsia@gmail.com Thank you!
*SSN will be destroyed immediately following background check.
Schools and Reading Times
2007-2008 School Year
* Please note: Power Lunch days/times are not confirmed yet for this school year. If you are a new volunteer and filling out the Volunteer Information Form, please write your availability on the form in the line provided. If you have a preferred school, please write that on the line provided at the top. Please feel free to leave the school location blank if you are unsure.
Capitol View Elementary
320 East 16th St., Des Moines
Monday 11:30-12:10 4th grade
Wednesday 11:40-12:20 3rd grade
Thursday 11:20-12:00 5th grade
Carver Community School
705 East University, Des Moines
Tuesday 11:00-11:40 5th grade
Wednesday 4:00-4:45 4:15-5:00
Friday 11:25-12:05 3rd grade
Christ the King School
701 Wall Ave., Des Moines
Thursday 11:30 -12:30 2nd Grade
Emerson Hough Elementary School
700 N. 4th Avenue, Newton
Tuesday 11:20-12:05 2nd Grade
Thursday 11:20-12:05 3rd Grade
Monroe Elementary
2250 30th St., Des Moines
Thursday 11:00-11:50 5th grade
Thursday 12:15-1:00 3rd grade
River Woods Elementary
2929 SE 22nd St., Des Moines
Thursday 11:45-12:25 2nd grade
South Union Elementary
4201 S. Union Street, Des Moines
Monday 11:40-12:20 3rd Grade
Tuesday 12:00-12:40 5th Grade
Walnut Street School
907 Walnut St., (Metro) Des Moines
Monday 11:00-11:40 Kindergarten
Wednesday 11:45-12:30 Preschool
Windsor Elementary
5912 University Ave., Des Moines
Monday, Wednesday, or Thursday
3rd grade 12:00 - 12:40pm
4th grade 12:05 - 12:45pm
5th grade 12:15 - 12:55pm