Young Men of Valor Application

2026 Mentee Application

Dear Parent/Guardian:


Young Men of Valor is a free year round mentoring program for fatherless, young men between the ages of 10 to 18. This means no father/step father is in the home. The program focuses on developing character and leadership among the program participants. Young men will meet once or every other week with young men in there communities who will hold them accountable and grow with each other to be positive leaders in there community and school.


Young Men of Valor assure that your son will have a mentor that visits them at school, sets goals, and holds them accountable. Your son will participate in group mentoring sessions, community service, and field trips throughout the year. They will also participate in leadership camps throughout the year.


Attached is an application for the custodial Parent/Guardian to complete.  On page two of the application there is a section for the child to write why he wants to be a part of Young Men of Valor.


Thank you for your interest and cooperation in completing the attached application. If you have any questions or concerns please call 334-245-4261


Sincerely,



Henry D. Tellis, Executive Director

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Child’s Name *
Age *
Birth date *
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Race *
Home Mailing Address: Street,City,State,Zip Code *
Guardian Cell Phone Number: *
Son Cell Phone Number: *
E-Mail Address (Parent/Guardian): *
E-Mail Address (Child): *
Current School Name: *
Current Grade Level: *
School Phone Number: *
Who has legal custody of child: *
 Grandparents Name and Phone Number: *
Who lives in your household with the young man now?  (List everyone living in your household, even if temporary)  Full Names and                                                 Relationship *
How often does your son see or talk to his father/step-father? *
Please describe their relationship with father/step-father? *
Confidential Information: Does your child have any emotional, physical, or behavioral conditions that might affect his program experience? If so, please explain: *
Who recommended you to Young Men of Valor? Name:     Relationship or Occupation: Phone Number:   *
CHILD – Please write in your own words why you want to be apart of  Young Man of Valor? *
MOTHER/GUARDIAN – Why do you want your son to be apart of  Young Man of Valor? *
COMMENTS – Please use this space for other information that would help us better meet your son’s needs. *
EMERGENCY CONTACTS: NAME: _____ RELATIONSHIP:_____ Cell/Home PHONE: (    ) __  -___   WORK PHONE: (     ) __-___  ADDRESS: *
EMERGENCY CONTACTS: NAME: _____ RELATIONSHIP:_____ Cell/Home PHONE: (    ) __  -___                      WORK PHONE: (     ) __-___  ADDRESS: *
HEALTH INFORMATION STATEMENT: PLEASE LIST BELOW ANY INFORMATION YOU FEEL THE STAFF MAY NEED TO MAXIMIZE THE SAFETY AND THE WELL BEING OF THE MEMBER.  PLEASE BE SPECIFIC INCLUDING ANY INFORMATION RELATING TO THE CONDITIONS LISTED.  IN CASE OF EMERGENCY, THIS HEALTH INFORMATION MAY BE THE ONLY SOURCE OF ACCURATE IMPORTANT INFORMATION.  THIS INFORMATION IS CONFIDENTIAL. *
Please Note:  All medications, which accompany the member to activities, will be given to the Mentor.  The Mentor will dispense medication in accordance with the directions provided by the parent/guardian.  All authorized over-the-counter and prescription medications should be listed on this form.ALLERGY TO MEDICINES (including penicillin, tetanus…) *
MEDICATION THAT NEEDS REFRIGERATION: *
Was your child on any medication during the school year?  If yes, please list name of medication and reason for prescription: *
MEDICINES CURRENTLY BEING TAKEN BY CHILD (including non-prescription or over-the-counter medications)*Please list names, doses, and times to be taken. *
Family Doctor's Name: *
Doctor Phone Number: *
Clinic/Hospital: *
City: *
Health Insurance Provider: *
Policy Number: *
I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME BEFORE MEDICAL PERMISSION IS GIVEN TO TREAT MY CHILD. As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given.  I further understand that in case of serious illness/injury, I will be notified.  However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician.  I also understand that if my child becomes ill or injured, my health insurance is primary coverage for those expenses. Please type first and last name with date below. *
A COPY OF YOUR SON’S MEDICAL INSURANCE CARD MUST BE INCLUDED BEFORE THE APPLICATION CAN BE PROCESSED
Child's Name: *
Young Men of Valor - Release of Liability-Child participant and parent/guardian must complete and sign in the presence of two (2) witnesses.This form must be completed and returned for your child to participate in the Young Men of Valor activities throughout the year.This Form Affects Your Legal Rights – Make Sure You Understand It Before Signing
I_______________, the undersigned, hereby represent that I am the parent/legal guardian of the program  participant and that I have the legal authority to execute this release. *
1. I accept your invitation and hereby agree to allow my child the opportunity to participate in the YOUNG MEN OF VALOR program and hereby authorize Young Men of Valor and Henry Tellis Foundation, employees, agents and licensees (“Releasees”) to use my child’s name, biography, photograph, likeness, and performance, for the purpose of creating marketing and information material, to promote the Young Men of Valor program to potential sponsors and financial contributors, to create awareness of the Young Men of Valor Program, and to establish additional grant funding for the Young Men of Valor program, in any and all formats, including but not limited to the internet, media, or through presentation. 2. I give Young Men of Valor permission to contact my son’s school, receive a copy of all records (including, but not limited to, attendance records, course grades, reprimands, scholastic achievements and physical education / sports participation) and communicate with school officials based on the discretion of those administering the Young Men of Valor program, and to use any of the above-referenced information and program records as referenced in paragraph 1 above. I understand that any identifiable information collected or obtained on my son or myself (whether from school officials or records, or as collected in the attached forms) will be kept as confidential information, and will only be used to evaluate the progress and growth of my son, and to grow the Young Men of Valor program. Nonetheless, in the event of an inadvertent or mistaken release of confidential information by the Young Men of Valor program or as a result of the improper actions of another (e.g., theft, hack), I agree to hold harmless, indemnify, release and further discharge Young Men of Valor, the Henry Tellis Foundation, and their trustees, officers, agents, servants and employees from and against any and all claims, demands and actions or causes of action on account of or resulting from the release of confidential information. 3.  I further understand that during Young Men of Valor activities, transportation will be required for certain events, including but not limited to: fishing, eating out, bowling or attending sporting events. In the event of inclement weather, Young Men of Valor staff may transport my child to another facility. Furthermore, participation in leadership camps and various events and activities is voluntary, and the undersigned are aware of, and agree to abide by the rules and regulations of the program. 4. In consideration for Young Men of Valor, permitting my child the opportunity to participate in these activities, I, in full recognition and appreciation of any risks, hazards or dangers inherent in the Young Men of Valor activities to which my child may be exposed, do hereby agree to assume all of the risks and responsibilities surrounding my child’s participation in such activities, with full knowledge and understanding that transportation to and from the program is not the responsibility of Young Men of Valor.  Further, I acknowledge as a condition for my child’s participation in the Young Men of Valor program, that I understand and agree to hold harmless and indemnify, release and further discharge Young Men of Valor, the Henry Tellis Foundation, and all of their trustees, officers, agents, servants and employees from and against any and all claims, demands and actions or causes of action on account of or resulting from my child’s participation in the Young Men of Valor Program. Understanding this condition to my child’s participation in the Young Men of Valor program, I agree to hold harmless and indemnify, release and further discharge the Young Men of Valor program, the Henry Tellis Foundation and all of their trustees, officers, agents, servants and employees from an against any and all claims, demands and actions or causes of action on account of or resulting from my child’s participation in the Young Men of Valor program. 5. In signing my name below, I acknowledge my full understanding of the risks involved in my child’s participation in these activities, including physical activities, which may include various sport and swimming activities, and transportation to and from various events.  I further acknowledge, as the person most knowledgeable, that my child is physically able to participate in such activities.  I understand that the Young Men of Valor program, the Henry Tellis Foundation, and all of their trustees, officers, agents, servants and employees assume and accept no liability for personal injury or loss of life or damage to personal property, and that pursuant to paragraph 5 above, that I have released, will hold harmless, and will indemnify the Young Men of Valor program, the Henry Tellis Foundation, and all of their trustees, officers, agents, servants and employees from all claims, demands and actions or causes of action brought against them as a result of my child’s participation in the program. 6. I acknowledge the opportunity to hire a lawyer to review and evaluate this Release of Liability. I understand that I enter into this Release of Liability under my own free will, that I was provided the time and opportunity to understand the contents of this Release, and I confirm that I do in fact understand it fully.  IN WITNESS WHEREOF, I have caused this Release to be executed on Date Below and Signature. *
Child Signature and Date: *
Witness and Date *
Witness and Date *
Transcript and Grade Release Form I give my permission for any employee of Young Men of Valor to contact _______________________’s school, meet with him during school hours, view or receive a copy of all his records, and communicate with school officials when necessary, as long as he is a member of Young Men of Valor.
Name of School_________CITY____STATE___Online Code to Access Grades:__ *
Parent or Legal Guardian: Type Signature *
Must be signed in order to be accepted into the Young Men of Valor Program.
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