I certify that the information provided in this application is true and complete to the best of my knowledge. If this application leads to enrollment, I understand that providing false or misleading information during the application or interview process may result in the removal of the youth named above from the program. Participation in this program is a privilege, not a right, and both the parent/guardian and the youth must understand this. Failure to follow the rules and regulations may result in the youth’s removal from the program at any time.

I, the parent or legal guardian of the youth named above, hereby give my permission for him to participate in the Champion Circle program. I fully understand that the program involves mentors selected from the community, all of whom will be screened and trained prior to their involvement. I acknowledge that I must participate in an orientation session where the program will be explained. I understand that Champion Circle will provide ongoing monitoring of the mentoring activities. I also give the program coordinator permission to obtain the academic and attendance records of the youth named above from his school. I grant permission for Champion Circle to use photographs of the youth taken during his participation in the program, and I waive any rights to compensation for their use. I understand that there is no fee for participation in the program; however, the youth named above is required to complete 5 community volunteer service hours every month.