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

PROTÉGÉ APPLICATION FORM

 

 

PROTÉGÉ'S FIRST NAME: LAST NAME:

 

NUMBER & STREET ADDRESS: Apt. #:

 

CITY: STATE: ZIP CODE:

 

HOME PHONE #: OTHER PHONE # (for example - grandparents, cel phone, etc.):

 

PROTÉGÉ'S E-MAIL ADDRESS:

PROTÉGÉ'S BIRTH DATE:

 

PROTÉGÉ'S SOCIAL SECURITY #:

 

1) PARENT/GUARDIAN: FIRST NAME: LAST NAME:

 

RELATIONSHIP TO PROTÉGÉ:

 

EMPLOYER OF PARENT/GUARDIAN: WORK PHONE #:

 

PARENT/GUARDIAN E-MAIL ADDRESS:

 

2) PARENT/GUARDIAN: FIRST NAME: LAST NAME:

 

RELATIONSHIP TO PROTÉGÉ:

 

EMPLOYER OF PARENT/GUARDIAN: WORK PHONE #:

 

PARENT/GUARDIAN E-MAIL ADDRESS:

 

PROTÉGÉS
WHAT ARE YOUR CAREER/JOB INTERESTS (list 3 choices):

 

1^st Choice-

 

2^nd Choice-

 

3^rd Choice-

 

PERSONAL INTERESTS & HOBBIES (what you like to do when you are not in school):

 

PROTÉGÉ’S CREED

 

I, , solemnly vow to make every possible effort to be an active participant and supporter of The Rotsky Foundation for Mentors.  I know it is my responsibility to contact my mentor at least once a month.  I will also make sure we see each other once a month, with the goal to build a long-term friendship with my mentor. I will notify a director immediately with any problems or situations that are blocking the development of the protégé/mentor relationship.

  

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

  

 

CLASS SCHEDULE              

                                                                               

Guidance Counselor’s Name:    Home Room Teacher’s Name:

 

      Please include      Subject               Time of Class                 Teacher’s Name                       

 

1) 

2) 

 

3) 

 

4) 

 

5) 

 

6) 

 

7) 

 

8) 

Proficiency Test (Passed or Failed):        

If failed, what parts did you fail:

 

Extra Curricular Activities: