SLAM Mentee Application

Mentee Name*
First Last
Age*
Current Grade Level*
Current School*
Current GPA*
Email Address*
Mentee Phone Number*
Home Address
Street Address Address Line 2 City State ZIP Code
Shirt Size*
Hobbies/Interest
Participant Race/Ethnicity*
- Black/African-American
- White/Caucasian
- Hispanic
- Asian
- Hawaiian
- Biracial
Have You Ever Participated in this Program Before?*
- First Time Participant
- Returning Participant
Parent Name*
First Last
Parent Phone Number*
Parent Email Address*
Annual Household Income*
(Answering this question will help us qualify for future grant opportunities)
Estimated Annual Income of Household*
How Many Youth Are Currently In Household?
Do You Plan To Attend/Participate In Other Successteam Programs*
- Yes
- No
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Emergency Contact Email Address*
Relationship to Mentee*
- Mom
- Dad
- Brother
- Sister
- Uncle
- Aunt
- Grandparent
Successteam Liability Waiver*
I agree to the Successteam Liability Waiver
By checking the box above for myself, my spouse, and/or my child knowingly and freely assume all such risks and give my permission to participate in any Successteam program/activity. I accept full responsibility for any injury which may occur, and will in no way whatsoever, hold the Successteam or any employee or representative of the Successteam responsible. The participant is allowed to participate in any way in this program, related events and activities: therefore, I agree that participant's likeness may be photographed or videotaped and that such image may be published in an outlet used to promote or publicize the program/activity.

The participant and others whose signatures are attached below do hereby consent to any and all medical and surgical treatments including anesthesia and operations which may be deemed advisable by physicians and surgeons. The intention hereof being to grant authority to administer and to perform all and singularly any examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the participant's care be deemed advisable or necessary. I also agree that the participant when admitted is to remain in the hospital until his or her physician recommends the participant's discharge. In witness of my consent and agreement to the matters stated in the three preceding sentences, I have subscribed my signature.
Successteam – USC Columbia Dorm Room Liability Waiver*
I agree to the Successteam – USC Columbia Dorm Room Liability Waiver
By checking the box above for myself, my spouse, and/or my child knowingly and freely assume all such risks and give my permission to participate in any Successteam program/activity. I accept full responsibility for any injury which may occur, and will in no way whatsoever, hold the Successteam or any employee or representative of the Successteam responsible.

By checking the box below for myself, my spouse, and/or my child; I accept full financial obligation for any disruptions, incidents, accidents, & vandalism to the University of South Carolina – Columbia Dorm Rooms while on campus during the Successteam Leadership Academy for Young Men presented by Successteam.

I agree to pay for all repairs and/or necessary maintenance in response to actions taken by myself, my spouse, and/or my child by submitting full payment to University of South Carolina – Columbia + $250.00 to Successteam for disruptive behavior.

SLAM Mentee Application

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