UT Rocket Kids Interest Form

Welcome! We appreciate your interest in the Rocket Kids program. Please complete the form below. We will use this information to determine if you are eligible for an interview with our team.

Student Information

First Name

Last Name

Birth Date

Email Address

Phone Number

Mailing Address

Country

Street

City

Region

Postal Code

Are you a US Citizen?

Yes

No

Do you have a U.S. Passport?

Yes

No

School Info

School Attending

Academic Major

Degree Received (if applicable):

Expected Graduation Date:

College GPA (minimum 2.5 Required) If you are an incoming freshman, please use your HS GPA:

Credit Hours Completed

Teaching/Childcare Experience

I have experience working in the following areas with children (Please choose all that apply):

Approximate total hours of experience working with children:

Are you able to provide references and proof of hours?

Yes

No

Please provide information for Paid and Volunteer work with Children/Youth below:

Employer/Agency #1

Job Title

Start Date

End Date

Hours per Week

Was this paid or unpaid work?

Employer/Agency #2

Job Title

Start Date

End Date

Hours per Week

Was this paid or unpaid work?

Employer/Agency #3:

Job Title

Start Date

End Date

Hours per Week

Was this paid or unpaid work?

Employer/Agency #4:

Job Title

Start Date

End Date

Hours per Week

Was this paid or unpaid work?

Additional Information

What term/year of entry are you interested in joining Rocket Kids?

Leadership experience/Honors/Awards:

I can lift 40 lbs and engage in strenuous activity:

Yes

No

Have you ever been charged with a felony or misdemeanor?

Yes

No

If yes, list the charge and when it was received:

I understand that Rocket Kids has a zero-tolerance drug policy. I agree to submit to a random drug test if requested by UToledo Rocket Kids Administrators:

Yes

No

I am committed to participating in the required training at The University of Toledo (and additional online components) to meet military requirements for participation:

Yes

No

Why do you want to participate in Rocket Kids?

Is there any other information that we should know about you to help determine your prior experience or eligibility?

Please list any coursework you have taken that relates to working with children:

Course Name/Title #1

College or University where completed

Course Name/Title #2

College or University where completed

Course Name/Title #3

College or University where completed

Course Name/Title #4

College or University where completed