Gene Xcellence Success Coach Application

Success Coach Application

Please complete the form below to apply for to become a Success Coach. Please be aware that being a Success Coach is a volunteer/intern opportunity that will require you to meet with student(s) at least twice a month for the duration of the program you select. Also, background checks will be required before becoming a Success Coach.
Full Name*

First NameMiddle NameLast Name
Email Address*
example@example.com
Phone Number*

Area CodePhone Number
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
How did you hear about us
If you picked "Referral," please list who referred you.

First NameLast Name
Available Start Date

MonthDayYear
Date
Which program do you want to be a part?

Intensive Excellence Program (middle & high school students)Wealthy Young Adult Program (ages 18-30)
What is your religion? If none, but N/A.
Why do you want to become a Success Coach?
What advice would you give a student who is feels stressed at home and/or school?
For example, if a student says they have to
What advice would you give a student struggling with their sexuality?
For example, if a 14 year old student says they gay and is afraid to be open. What is your response?
What advice would you give a student that is on the verge of failing school?
What advice would you give a student that lacks self-discipline?
What advice would you give a student that lacks self-confidence?
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