Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

CFC has a few volunteer options; mentor and volunteer. Mentors make a 1-year commitment to coming to our ROOTED program consistently. At ROOTED they sit in with an unmatched student. After a minimum of 3 months, they can get matched with a mentee. It is our hope and desire that matches recommit year after year but we understand that circumstances do not always allow for this. Though all roles are voluntary, please choose "Volunteer" if you will be an occasional volunteer at ROOTED. Our volunteer role can be in a variety of capacities. Some of these are helping with tutoring, volunteering at ROOTED in the School (during the school day), assisting with snack, set-up, clean-up at ROOTED. Running audio/video at ROOTED. *

Mentor

Volunteer

Media release *

I hereby grant to Center for Champions and those acting under its authority, to record on film, tape or otherwise my name, likeness, voice, performance and actions. I acknowledge that my performance may be edited as desired by Center for Champions and may be used in perpetuity and authorize others to use, such recording as Center for Champions sees fit on television and radio broadcasts, audio-visual use, in any production, in any and all media now known or hereafter devised throughout the world, and to use, license, market, and distribute in any medium or forum said productions and any other productions in which said recording may be incorporated. I waive the right to inspect or approve any such use of my child’s name or my name, likeness, voice or actions, and hereby also authorize Center for Champions and those acting under its authority to use my name or my name, likeness, voice, actions, biography, and/or composition for purposes of promotion and publicity in connection with the program material. Further, I hereby waive and forego any compensation for my appearance in the production. I release Center for Champions from all claims and liabilities of any kind arising out of or in connection with the making or uses of such films or recordings. The rights granted herein shall insure to the benefit of Center for Champions, its licensees, successors and assigns.

Yes

No