The Rotsky Foundation                            (Copied from www.rotskyfoundation.org)

PARENT APPLICATION FORM

 

MY CHILD'S NAME IS (PROTÉGÉ):

 

PARENT/GUARDIAN #1:

 

FIRST NAME: LAST NAME:

 

NUMBER & STREET ADDRESS: Apt. #:

 

CITY: STATE: ZIP CODE:

 

HOME PHONE #: EMERGENCY PHONE #:

 

RELATIONSHIP TO PROTÉGÉ:

 

EMPLOYER OF PARENT/GUARDIAN: WORK PHONE #:

 

PARENT'S E-MAIL ADDRESS:

 

PARENT/GUARDIAN #2: (If applicable)
 

FIRST NAME: LAST NAME:

 

FIRST NAME: LAST NAME:

 

NUMBER & STREET ADDRESS: Apt. #:

 

CITY: STATE: ZIP CODE:

 

HOME PHONE #: EMERGENCY PHONE #:

 

RELATIONSHIP TO PROTÉGÉ:

 

EMPLOYER OF PARENT/GUARDIAN: WORK PHONE #:

 

RELATIONSHIP TO PROTÉGÉ:

 

PARENT/GUARDIAN E-MAIL ADDRESS:

 

PARENT/GUARDIAN CREED 

 

I (we), , solemnly vow to make every possible effort to support my child and his/her efforts in The Rotsky Foundation for Mentors.  I will help transport my child, when possible, to meetings, give my child messages from their mentors, and will work to make sure that my child is an active, enthusiastic participant in the program.  I will notify a director immediately with any problems or situations that are hindering the development of the protégé/mentor relationship, including the protégé not having a working phone number to be reached by the mentor or a director.

  

 Type YES if you agree and commit to the Protégé's Creed       Date

  

MEDICAL TREATMENT AUTHORIZATION, LIABILITY RELEASE & WAIVER

  

     I (we), , do hereby grant my permission for my son/daughter, (name of protégé), , to attend and fully participate in all activities of The Rotsky Foundation for Mentors program.

 

     In order that my son/daughter may receive the necessary medical treatment in the event of injury or illness, by submitting this form on line, I hereby authorize The Rotsky Foundation for Mentors program to obtain medical treatment for my son/daughter for such an injury or illness during said activity or program.  I hereby agree to release The Rotsky Foundation for Mentors program, its agents, its employees, and representatives from any and all claims and liability arising in any way out of its exercise of this authority.

 

     By submission of this form on line, I also grant permission to the health service provider and/or agency to provide verbal and written medical and other information to The Rotsky Foundation for Mentors program.

 

     I understand and agree that it is my responsibility to pay all bills for medical care and treatment for my son/daughter, in the event that such medical care is necessary.

 

     I further acknowledge, understand, and agree that physical illness or injury may result from participating in some activities of this program, and that my son/daughter is assuming the risk of such illness and injury by his/her participation.  I further acknowledge by submitting this form/agreement this is a waiver of liability as it relates to injury to my son/daughter and agree to hold The Rotsky Foundation for Mentors harmless for such injury.

 

I ACKNOWLEDGE THE ABOVE STATEMENT AND SUBMIT MY AUTHORIZATION AND AGREEMENT TO THIS WAIVER BY PLACING A "YES" IN THE BOX BELOW.

 

Type YES if you agree and commit to the Waiver       Date

 

NAME OF INSURANCE COMPANY:  

 

STREET ADDRESS OF INS. CO:

 

CITY: STATE: ZIP CODE:

 

INSURANCE POLICY NUMBER:

 

LIST ANY MEDICAL PROBLEMS THE PROTÉGÉ HAS & PLEASE INCLUDE MEDICATIONS CURRENTLY TAKING AND DOSAGE:

 

4) Type in the box below what appears in the picture: