Mentor Banner Image.jpg

Teen Information

Name Address
Postal Code Phone
Email DOB
Gender School
School Phone Guidance Counselor
Guidance Counselor's email:  Grade

 
References

Reference 1
Reference 2
Reference 3
Can You Speak Any Other Languages?  


Please Click All Activities and Hobbies You Are Interested In;
To make multiple selections, please hold down the CTRL key 

Do you have any previous experience volunteering or working with kids
Are there any skills you are bringing to this program?  (i.e. CPR, camp counselor, etc.)
Do you prefer a male or female mentee?   Male    Female
Is there anything else we should know about you that can assist us in matching you up with an appropriate mentee?
Do you have a pre-selected student you would like to work with?   Yes    No
If Yes what is their name?  
Would you be interested in working with another student if the student you listed above is not accepted to the program?   Yes    No    N/A


T-Shirt Size:  


Academic Preferences

English Subjects:
English Social Studies Math Science
History French Other:
Hebrew Subjects:
History Talmud Ivrit Toda'ah
Torah Naach Other:



Emergency Information  

Emergency Contact Phone
Are there any medical issues that we should be aware of?



Information Release

I authorize the Tenafly Student Exchange Program to obtain any needed information regarding my child from his/her school staff, including academic and behavioral records with teachers, counselors and other administrative staff.

Parent/Guardian Date


TSX Rules, Regulations & Expectations

Please read this carefully before signing:

A. I am committed to being at every TSX training session, meeting and follow up meeting for the duration of the TSX session. I am aware that failing to be consistent and lack of commitment will be a disappointment to my Mentee and the TSX directors, and will lead to my being excused from the TSX program.

B. I am aware that any problems, concerns or suggestions concerning my mentee will only be discussed with a member of the TSX advisory board and will be treated as highly confidential information.

C. Throughout the TSX program, I feel confident that I can supervise, assist and mentor the child that will be assigned to me. I realize that although there will always be adults on hand, the child placed under my care will be my responsibility.

D. TSX participants are expected to maintain proper decorum and attitude during the entire program. Disruptive behavior (including, among other things, sexual or other inappropriate innuendo) will not be tolerated in any way, shape or form, and may lead to my being excused from the TSX program.

Our program appreciates your interest in becoming a mentor to a child.  By submitting this form, you attest to the truthfulness of all information listed on this application.  I have read and understood the program's rules, regulations, and responsibilities.  If selected, I will follow the rules of the program and apply myself wholeheartedly.