Step Down Program Application

Step Down Program Application

For Team Up Connections' Graduates
Team Up Connections
9424 Harrisburg Road
Charlotte NC 28215
(704) 905-5849
TeamUpConnections.org
Robin@TeamUpConnections.org

Link to This Form:
https://form.jotform.com/262018162760149

The Step Down Program is a 6 Month Extension for Mentees
who would benefit from continued involvement
with Team Up Connections after graduating.
Mentee Contact Info
Mentee's Name:

First NameLast Name
Mentee's Birthday:

MonthDayYear
Date
Mentee's Current Age:
Mentee's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Mentee's Email Address:
example@example.com
Additional Email Address:
example@example.com
Mentee's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mentee's Emergency Contact Name:

First NameLast Name
Mentee's Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Mentee's Relationship with Emergency Contact:

Other
Is there anything else we should know about the Mentee (medical info, allergies, etc)?
Parent/Guardian Contact Info

(If Applicable)
If Mentee is a minor (under 18), we will need the Parent/Guardian to fill out this application as well. Please provide your contact info below (if applicable).
Parent/Guardian Name (if applicable):

First NameLast Name
Parent/Guardian Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address:
example@example.com
Parent/Guardian Address (if different from Mentee's Current Address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Status of Mentee
Please select all that apply to Mentee currently:

Other
Current grade (if still in school):
School Name (if applicable):
School Address (if applicable):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do we have permission to pick up Mentee from school on the Team Up Connections' bus?
Do we have permission to pick up Mentee from home on the Team Up Connections' bus?
Court Counselor's Name (if applicable):

First NameLast Name
Court Counselor's Phone Number (if applicable):

Area CodePhone Number
Graduation & Referral Info
Are you a graduate of the Team Up Connections program?
What were the start and end dates of Mentee's prior Team Up Connections' Enrollment?
Date Started with Team Up Connections:

MonthDayYear
Date
Date Graduated from Team Up Connections:

MonthDayYear
Date
What Year(s) have you been a part of Team Up Connections?
Who is Referring You to Continue as a Team Up Connections Mentee in the Step Down Program?
Please share how you believe the Step Down Program would benefit the mentee/yourself (if you are the returning mentee).
How long do you plan to stay in this extension period with Team Up Connections?
Enrollment Signatures
Mentee's Name:

First NameLast Name
Mentee's Signature:
Parent/Guardian Signature (if applicable):
Today's Date Serves as the
Date of the Mentee's Official Enrollment
to Team Up Connections' Step Down Program.
Today's Date:

MonthDayYear
Date
Signature of Director/Operator (or other designated staff member):

Robin Sturdivant
Staff Notes
Should be Empty:

Step Down Program Application

Mentee Contact Info

Parent/Guardian Contact Info

Current Status of Mentee

Graduation & Referral Info

Enrollment Signatures