The Rotsky Foundation

MENTOR APPLICATION FORM

 

NAME:______________________________________________________________________________

 

STREET ADDRESS:___________________________________________________________________

 

CITY:__________________________________ STATE:____________ ZIP CODE:_________________

 

HOME PHONE #: (_____)____________________ E-Mail Address: _____________________________

 

WORK PHONE #: (_____)____________________ FAX PHONE #: (____)________________________

 

SOCIAL SECURITY #:___________________________ DATE OF BIRTH:________________________

 

EMPLOYER:_________________________________________________________________________

 

EMPLOYER’S ADDRESS:______________________________________________________________

 

CITY:______________________________________ STATE:____________ ZIP CODE:_____________

 

OCCUPATION:_______________________________________________________________________

 

EDUCATION:_________________________________________________________________________

 

PROFESSIONAL ORGANIZATIONS OR AFFILIATIONS:______________________________________

 

____________________________________________________________________________________

 

PERSONAL INTERESTS & HOBBIES:_____________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

PLEASE LIST ANY ADDITIONAL ORGANIZATIONS WITH WHICH YOU ARE, OR HAVE BEEN, INVOLVED AS A VOLUNTEER:__________________________________________________________

 

 

Mentor please complete and return this application form to:

      The Rotsky Foundation for Mentors

      781 Village Trails

      Gates Mills, OH. 44040

 

 

Call Gina Rotsky at (216) 556-4793 with questions.

 

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