C.H.A.M.P. Inc. Mentee Application
Email *
Date of Application *
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Agency Involved
Parent/Guardian Name *
Child's Name *
Pleas also include any preferred nicknames
Child's Date of Birth *
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Race *
Required
Address *
Adrress, City, St, & Zip
Home Phone *
Other Phone
Does your child take any medications? *
If yes, please list medications and dosages:
Please list other children in the family?
Name, DOB, Sex, Lives at home?
List all other people living in your home and their relationship to your child: *
Please list family members that are allowed to pick up your child: *
Please list family members that are allowed to pick up your child:
Please note any special comments or questions you may have:
Income Information
This information will be kept confidential and is requested for statistical purposes only.
Number of people living in your home:
Total household annual income:
Sign, Date, & Submit
Type your name to serve as a digital signature: *
Submission Date
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Submit
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