Mentor Registration

Centralia Super Heroes Mentor Registration

All persons wishing to be Centralia Super Heroes mentors should fill out the following information. Currently, all mentoring occurs lunch time (see times below) at Centralia Junior High School. We are hoping to expand our program to include more area schools soon. Please call 548-2959 for more information.

Please complete the following for our records. This information will only be used for contacting you for the Super Heroes program and will not be given to any other parties. You will be contacted by the Super Heroes staff and given further directions on completing your background check and training for a Super Heroes Mentor. Congratulations on your committment to be a part or such an important service to your community!

First Name:

Last Name:

Address:

City:

State:

Zip:

Home Phone:
Cell Phone:
Email Address:

Please enter the number of hours you have to devote to mentoring each month (4 or more)

Please check the days of the week and times you have available.

Monday

Tuesday

Wednesday

Thursday

Friday

Lunch 1
10:48-11:30

Lunch 2
11:33-12:15

Lunch 3
12:18-1:00

I understand that I will be required to submit to a background check.

You must click the "submit" button below to complete this application.