Mentees form | Champions Circle

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Champion Circle Mentee application

To participate in the Champion Circle Program, this application must be fully completed and signed, including the parent/guardian consent section. Incomplete applications will not be considered. All teens are encouraged to also complete an application with the Give A Day Foundation to track their volunteer hours. Participants are required to complete five hours of community service each month. The Give A Day Foundation offers volunteer opportunities and can help teens meet these requirements.

Date

Mentee information

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone number *

Email *

Date of Birth *

Preferred T-Shirt Size *

Which school do you currently attend? *

Academic Grade *

Current Grade Point Average (GPA) *

Parent/Guardian information

Parent or legal guardian *

Mother
Father
Mother & Father
Guardian

Mother's name *

First

Last

Mother's address *

Address Line 1

City

State

Zip Code

Mother's phone number *

Mother's email *

Father's name *

First

Last

Father's address *

Address Line 1

City

State

Zip Code

Father's phone number *

Father's email *

Guardian's name *

First

Last

Guardian's address *

Address Line 1

City

State

Zip Code

Guardian's phone number *

Guardian's email *

Emergency contact

Please provide the name and contact information of someone we can reach in case of an emergency.

Name *

First

Last

Phone *

Relationship to Applicant *

Program commitment

Champion Circle is designed to develop leadership, personal growth, and community engagement. As part of this program, mentees are required to: ✅ Attend scheduled meetings and events ✅ Participate in workshops and activities ✅ Complete at least 5 hours of community service per month

Mentee areas of interest

Please select the areas in which you are interested or would like guidance: *

Academic Support: Help with study skills, organization, and tutoring in challenging subjects
Emotional Well-being: Guidance on managing stress, emotions, and building resilience.
Social Skills: Developing healthy friendships, resolving conflicts peacefully, and understanding boundaries.
Health and Fitness: Encouragement to stay active, eat well, and understand the importance of physical health.
Career Exploration: Introducing different career paths, offering resume building workshops, and mock interviews.
Financial Literacy: Teaching about budgeting, saving, and understanding the basics of personal finance.
Life Skills: Learning practical skills like cooking, household management, and time management.
Community Involvement: Encouraging volunteerism, civic engagement, and understanding the impact of giving back.
Personal Development: Setting goals, building self-confidence, and exploring interests and passions.
Safe and Ethical Internet Use: Educating on internet safety, responsible social media use, and digital footprint awareness.
Other

If other please explain:

Briefly tell us how you hope this program will benefit you and what are your expectations for this program: *

Does your teen have any allergies? *

If yes, please list all types of allergens, including food, environmental, and medication allergies.

If yes, list them below.

Does your teen take any prescription medication?

If yes, please list the medication name(s) and purpose.

Disclaimer and Acknowledgment: Please read and acknowledge the following information before proceeding:

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.

Mentee name *

First

Last

Mentee signature

Parent/Guardian Consent:

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.

Parent/Guardian name *

First

Last

Parent/Guardian signature *

Parent/Guardian agreement: *

I agree

Champion Circle Mentee application

Mentee information

Parent/Guardian information

Emergency contact

Program commitment

Mentee areas of interest

Disclaimer and Acknowledgment: Please read and acknowledge the following information before proceeding:

Parent/Guardian Consent:

Give A Day Foundation

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Give A Day Foundation

Champions Circle

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