mentee form

Child Information  

Name Address
Postal Code Phone
Email DOB
Gender School
School Phone Name of Guidance Counselor
Grade    
Can Your Child Speak Any Other Languages  
Has Your Child Ever Had a Mentor Yes     No  
Do You Prefer a Male or Female Mentor Male    Female  
Do You Have a Pre-Selected Mentor Yes     No  
If Yes, Name:  

Would you be interested in being paired with another mentor if the mentor you requested is not accepted to the program?

Yes     No     N/A
Are you currently enrolled in ESL? Yes  No  N/A  
If Yes, for how long?  
Has your child ever had a psychological assessment Yes  No  N/A  
If Yes, When?  
Does your child have any other tutors  
Please click all activities your child is interested in To make multiple selections, hold down the CTRL key
T-shirt Size  

Emergency Information  

Emergency Contact Phone
Are there any medical issues that the mentor should be aware of?
Are there any allergies that the mentor should be aware of?
Ohip #:

Which Subject Would Your Child Like Help With?

English Subjects:
English Social Studies Math Science
History French Other:
Hebrew Subjects:
History Talmud Ivrit Toda'ah
Torah Naach Other:
Please list any other academic issues (attendance, discipline problems etc)
Is there anything else we should know about your child that would assist us in matching him/her with an appropriate mentor:



Information Release:

I authorize TSX Tenafly Student Exchange Program to obtain any needed information regarding my child from his/her school's staff, including academic and behavioral records with teachers, counselors, and other administrative staff.  Furthermore, I understand that basic information about my child will be anonymously shared with a prospective mentor(s) to aid in determining a suitable match. Once a mentor and mentee are successfully matched up, my identity, my child’s identity, and any relevant information will then be shared with the mentor. 

 

The following persons are authorized to pick up my child:
Name Name
Name Name
Parent/Guardian Date



Registration:

Please note that the registration fees are not payment to the volunteers for their work.  All fees are tax-deductible donations that will be used to fund special TSX Chesed project and for our Youth Center.

*Fee $400
Name on Card: Method of Payment:
Card Number: Expiration:
*Please note: The cover charge for special outings is not included in the TSX Registration