Wufoo

Nominators Contact Information
First Name *
Last Name *
Title *
Local Program *
Phone Number * ### - ### - ####
Email: *
Mentor Information
First Name *
Last Name *
Employer *
Title *
Address: *
Email: *
Phone Number * ### - ### - ####
Total Number of TSIC Students Mentored? *
Information about students mentored through TSIC

Please share information about the mentors student(s). If the mentor has more than 3 students, just share the details on the top 3 below.
Student Name *
Years mentoring this student: *
Tell us about the student's current status: *
in Middle School in High School currently enrolled in College a College Graduate did not complete High School did not complete College
If the student is enrolled or attended college - where?
Student Name
Years mentoring this student:
Tell us about the student's current status:
in Middle School in High School currently enrolled in College a College Graduate did not complete High School did not complete College
If the student is enrolled or attended college - where?
Student Name
Years mentoring this student:
Tell us about the student's current status:
in Middle School in High School currently enrolled in College a College Graduate did not complete High School did not complete College
If the student is enrolled or attended college - where?
Nomination questions
HOW HAS THIS TSIC MENTOR SURPASSED OTHERS IN THE MISSION OF THE TAKE STOCK IN CHILDREN PROGRAM?
HOW HAS THIS MENTOR HAD AN IMPACT ON THE ACADEMIC AND PERSONAL SUCCESS OF HIS/HER MENTEE(S)? 1500 WORDS OR LESS *
Maximum Allowed: 1500 words. Currently Used: 0 words.
STATEMENT FROM CURRENT MENTEE SUPPORTING MENTOR'S NOMINATION (MAY BE TYPED BY STAFF BUT MUST BE IN MENTEE'S OWN WORDS) 1000 WORDS OR LESS *
Maximum Allowed: 1000 words. Currently Used: 0 words.

Please include the student's name.
STATEMENT FROM FORMER MENTEE (GRADUATE) SUPPORTING MENTOR'S NOMINATION (MAY BE TYPED BY STAFF BUT MUST BE IN MENTEE'S OWN WORDS) 500 WORDS OR LESS *
Maximum Allowed: 500 words. Currently Used: 0 words.

Please include the former student's name.
Please provide a high resolution photo of your nominee.
Attach a File *
*By clicking submit, I accept that any student/mentor/local program information provided may be used in TSIC promotional materials, provided to media as quotes, or presented at the TSIC conference. I have discussed this with the student(s) providing the above nomination(s), and I have media release forms on file for any student under age 18.
Do Not Fill This Out

Wufoo

Nominators Contact Information

Mentor Information

Information about students mentored through TSIC

Nomination questions

Please provide a high resolution photo of your nominee.