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Protégé Application - 18 and over

 

Please complete the form below and submit. If you have any questions please contact:

Richie Flores
314 E. Highland Mall BLVD
#253
Austin, Texas 78752
512-323-5444
rflores@nfb-texas.org

first, middle, last

e.g., Glaucoma, Retinitis Pigmentosa, ROP, etc.

Please read this carefully before sending:

The National federation of the Blind of Texas Mentoring program appreciates your interest in becoming a protégé.

After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if you have been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match you with an appropriate mentor. Therefore, the mentoring staff at times may need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is initial interest from the protégé, parent/guardian, and mentor based first upon anonymous information provided about each other.

Please check each of the following if you are granting consent:

I agree to follow all mentoring program guidelines and understand that any violation on my part may result in suspension and/or termination of the mentoring relationship.

I hereby acknowledge that I may be transported by my mentor and/or National Federation of the Blind of Texas program staff or representatives while participating in the National Federation of the Blind of Texas mentoring program and that such transportation is voluntary and at my own risk.

I agree to release the National Federation of the Blind of Texas mentoring program of all liability of injury, death, or other damages to me, my family, estate, heirs, or assigns that may result from my participation in the program, including but not limited to transportation, and hold harmless any National Federation of the Blind of Texas program mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

(Optional) I agree to allow the National Federation of the Blind of Texas program to use any photographic image of me while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

I understand that I must complete this Application and Interest Survey Form fully, and that any incomplete information will result in the delay of my application being processed.

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