AFTER-SCHOOL PROGRAM APPLICATION
Date of Birth
Primary Phone Number
Other Phone Number
District Of Columbia
Northern Mariana Islands
Are you over the age of 18?
Yes, I am 18 years old or older
No, I am under 18 years old
Parent or Guardian Information
Relationship to you
Parent/Guardian Phone Number
Parent Mailing Address
Decline to state
Decline to state
Please list any languages spoken other than English.
How did you hear about us?
Colleagues or professional network
Friends or family
Presentation at your school/work
Santa Clara University Arrupe
Are you a Breakthrough student?
Education, Work Experience and Skills
Highest level of education
High School or GED
Two Year College, Vocational or Technical Degree
Four Year College Degree
Are you the first generation, in your family, to go to college?
High School Name
Expected High School Graduation Year
High School Graduation Year
Undergraduate College Name
Undergraduate College Year
Graduate College Name
Graduate College Program
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Emergency Contact Full Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please list any medical conditions or allergies Breakthrough Silicon Valley should be aware of. Put N/A if there is none.
Please select the site(s) and time frame(s) you would be available to facilitate:
FMSD: Sylvandale Middle School, 653 Sylvandale Ave, 95111. Monday & Wednesday, 3:30-5:30 PM
FMSD: Bridges Academy, 1702 McLaughlin Ave, 95122. Tuesday & Thursday, 3:30-5:30 PM
Hoover Middle School, 1635 Park Ave, San Jose, 95126. Monday & Wednesday 4:30-6:30 PM
Hoover Middle School, 1635 Park Ave, San Jose, 95126. Tuesday& Thursday 4:30-6:30 PM
Please list any prior experience working with students.
Please list any prior leadership or community service experience.
Are you a returning volunteer?
Yes, I am returning math coach
No, I am new
Please reflect on your previous experience. In what ways have you grown? What areas would you like to improve on this year?
Do you have any questions or concerns about volunteering?
Questions, Comments, or Concerns
I understand that there will be required training I need to complete prior to volunteering in the after school program
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