CHAMPS APPLICATION 2016-17
ONLINE FORM
SCHOOL NAME
Your answer
LAST NAME
Your answer
FIRST NAME
Your answer
EMAIL ADDRESS
Your answer
CELL PHONE NUMBER
Your answer
ARE YOU A GARY COMER YOUTH CENTER MEMBER
ADVISOR
Your answer
GRADE
Your answer
PHONE NUMBER
Your answer
BIRTHDATE
MM
/
DD
/
YYYY
PARENT/GUARDIAN'S NAME
Your answer
T-SHIRT SIZE
WHAT ARE YOUR HOBBIES?
Your answer
WHAT QUALITIES YOU LIKE IN A MENTOR?
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WHAT INDIVIDUAL HAS SERVED AS A ROLE MODEL FOR YOU? WHY?
Your answer
WHO ARE YOU GOING TO BECOME AFTER COLLEGE?
Your answer
WRITE A BRIEF STATEMENT ON WHY YOU HAVE CHOSEN TO PARTICIPATE IN THE MENTOR PROGRAM?
Your answer
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