Supreme Athlete Mentee Application

Mentee Application

(To Be Completed by the Parent/Guardian)

Parent/Guardian Name:

Relationship to Youth:

Emergency Contact Name:

Highest level of education completed by parent/guardian:

Does your son/daughter have any physical problems or limitations?

Is your son/daughter currently receiving treatment for any medical issues?

Is he/she currently on any type of medication? Is so, please specify.

Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below

Does your son/daughter have any emotional issues or problems right now?

Is your son or daughter currently seeing a counselor or therapist?

Please initial each of the following

I give my informed consent and permission for my child to participate in the Supreme Athlete Mentoring Program and its related activities.

YES NO

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

YES NO

I release the Supreme Athlete Mentoring Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Supreme Athlete mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

YES NO

I agree to allow Supreme Athlete to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

YES NO

Contact and Information Release (FERPA)

I hereby grant permission for Supreme Athlete Mentoring Program to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee. Supreme Athlete may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the mentoring program.

I authorize Supreme Athlete to obtain any needed information regarding my child from his/her school’s staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.

Mentee Interest Survey

(To Be Completed by Youth)

Please complete all the following. This survey will help Supreme Athlete Mentoring Program know more about you and your interests.

Who is your role model, and why?

What are your favorite subjects in school?

If you could learn about a job/career, what would it be?

Who is your favorite athlete?

Which college are you most interested in attending, and why?

How did you hear about SA?

Explain why you would like to join Supreme Athlete?

Parent/Guardian Contract

By allowing my son/daughter to participate in the Supreme Athlete Mentoring Program, I agree to:

Allow my child to participate in the Supreme Athlete Mentoring Program.
● Encourage my child to follow all rules and guidelines as outlined by the program coordinator.
● Display loyalty by committing to Supreme Athlete Mentoring Program and its affiliated programs by not participating in any other similar training groups or programs during the duration of enrollment.
● Support my child in this program by allowing him to meet at least eight to twelve hours per month.
● Support my child being on time for scheduled sessions or have him/her call the mentor at least 24 hours beforehand if unable to make a session.
● Regularly and openly communicate with the program coordinator.
● Inform the program coordinator if I observe any difficulties or have areas of concern with behaviors or development.
● Ensure my child adhere to attending at least 75% of programming days.
● Notify the program coordinator if I have any changes in address or phone number.
● Provide the program coordinator and the mentor with any updated health related information for my child.
● Pay a late fee of $20 if I’ am late (10 minutes or more) picking up my child from the program
. ● Make payments on-time.
● Understand that we operate like a traditional gym membership. Any missed days will not be accommodated UNLESS we cancelled programming.

By choosing to participate in the Supreme Athlete Mentoring Program, I agree to:

● Follow all rules and guidelines as outlined by the program coordinator.
● Have a positive attitude and be respectful of all staff/volunteers.
● Make at least a 3-month commitment.
● Be on time for scheduled sessions or call at least 24 hours beforehand if I am unable to make a session.
● Discuss monthly meeting times and activities with the program coordinator, and regularly and openly communicate with the program coordinator as requested.
● Inform the program coordinator of any difficulties or areas of concern that may arise.
● Notify the program coordinator if I have any changes in address or phone number.
● Display loyalty by committing to Supreme Athlete Mentoring Program and its affiliated programs by not participating in any other similar training groups or programs during the duration of enrollment.

I agree to follow all the above stipulations of this program as well as any other conditions as instructed by the program coordinator at this time or in the future.

Contact Info

Supreme Being Inc.
P.O. BOX 271 Hartford, CT 06141

Email: info@supremebeinginc.com
United Way Campaign: Code DS1135
Public Charity Exemption #: CHR.0056683

860-983-0892