NOMINATION FORM Please complete nomination form and submit by by 5pm October 12, 2012. Send completed Nomination Form via first-‐ class mail to: The Steve Harvey Mentoring Program For Young Men-‐Chicago, P.O. Box 52817, Atlanta GA 30355. Nominee must be a young man from a single female head of household who is 13-‐18 years old and enrolled in grades 9-‐ 12 as of the date of submission. Please type or print Please attach a photo of the young man with this application Nominee: Check one: £ I am nominating myself £ I am being nominated by someone else First Name ____________________________ M.I. _______ Last Name _________________________________ Street Address (No P.O. Boxes Please. Include Apt./Ste. if applicable.) ________________________________________________________ City___________________ State ______ Zip Code _____________ Date of Birth: (Month/Day/Year) ____ /____/____ School Information Name of School Grade Level & Age of Nominee (at time of submission) ______ ______ Phone Number of School: ___________________________ City___________________ State ______ Zip Code _____________ Please check the following: Shirt Size: Small Medium Large XL/Other Shoe Size: ________ Pant Size: __________ www.smharveyfoundation.org SECTION A -‐ Parent/Legal Guardian Printed Name: _____________________________ Relationship to Nominee: ________________________ Daytime Phone Number: ______________________________ Street Address (No P.O. Boxes Please. Include Apt./Ste. if applicable.) ________________________________________________________ City___________________ State ______ Zip Code _____________ By signing below I authorize the consideration of my child/legal charge for a selection in The Steve & Marjorie Harvey Foundation’s Program. I have read and understand, and I and my child/legal charge, have fully complied with the Official Guidelines. I have reviewed this completed form in its entirety and agree that this form has been properly completed. All information is true to the best of my knowledge and belief. I understand that if my child/legal charge is selected, I grant to The Steve & Marjorie Harvey Foundation (the “Sponsor”) and all coordinating agencies the right to use my and my child’s/legal charge’s name, address (city and state), photograph, videotape or any likeness of me or my child/legal charge, and statements made by or attributed to me or my child/legal charge relating to the promotion of The Steve Harvey Mentoring Program For Young Men, for any lawful purpose, including, without limitation, advertising, publicity and other commercial purposes, in any and all forms and media, including without limitations, the Internet, throughout the world without further compensation. I, on behalf of my child/legal charge, hereby assign all rights, title and interest, including and without limitation copyright rights to this submitted form, to the Sponsor and its assigns. Check one: £ Nominee is under 18 years of age £ Nominee is 18 years or older Signature: ________________________________________ Date _____/_____/______ E-‐Mail Address: ____________________________________ I acknowledge I am the parent/legal guardian of the nominee above. Section B: Nominee’s Essay Question must be minimum 300 words, hand written or typed on an 8” x 11” sheet of paper attached to the Nomination Form by all nominees (Any essay submitted that is not written by the young man will automatically disqualify the entire application). Essay Question: How do you think not having a father in your life has affected you and how do you think attending Steve Harvey's Mentoring Weekend for Young Men will influence you? __________________________________________________________________________________________________ Please rank the following from 1-‐10 according to your level of concern (10 being the most concern and 1 being the least): Bullying ___ Gang Violence ___ Drug/Alcohol Abuse ___ Tutoring ___ Physical Abuse ___ Legal Issues ___ Emotional/Mental Illness, ___ Anger Management ___ Domestic Violence ___ Sexual Abuse ___ www.smharveyfoundation.org SECTION C: Students age 18 years or older (to be completed ONLY by students 18 years or older) By signing below I acknowledge that I have read and understand, and I have fully complied with the Official Guidelines. I have reviewed this completed form in its entirety and agree that this form has been properly completed. All information is true to the best of my knowledge and belief. I understand that if I am selected, I grant to The Steve & Marjorie Harvey Foundation (the “Sponsor”) and all coordinating agencies the right to use my name, address (city and state), photograph, videotape or any likeness of me, and statements made by or attributed to me relating to the promotion of The Steve Harvey Mentoring Program For Young Men, for any lawful purpose, including, without limitation, advertising, publicity and other commercial purposes, in any and all forms and media, including without limitations, the Internet, throughout the world without further compensation. I hereby assign all rights, title and interest, including and without limitation copyright rights to this submitted form, to the Sponsor and its assigns. Signature: ________________________________________ Date _____/_____/______ Nominee’s Printed Name: _____________________________ Nominee’s Daytime Phone Number: ________________ SECTION D: Nominator (to be completed by all nominators. If student is nominating himself, then skip to Section F) I hereby certify the information I have provided on this form is true to the best of my knowledge and belief. I also certify that I have read and understand and I have fully complied with the Official Guidelines. I understand that if the child I nominated is selected, I grant to The Steve & Marjorie Harvey Foundation (the “Sponsor”) and all coordinating agencies the right to use my name, address (city and state) photograph, videotape or any likeness of me and my statements made by or attributed to me relating to the promotion of The Steve Harvey Mentoring Program For Young Men, for any lawful purpose, including, without limitation, advertising, publicity and other commercial purposes, in any and all forms and media, including and without limitations, the Internet, throughout the world without further compensation. I hereby assign all rights, title and interest, including copyrights to my portion of this submitted form to the Sponsor and its assigns. Nominator’s Printed Name: ______________________________ Daytime Phone Number: ________________________________ E-‐Mail Address:______________________________________________________________ Signature: ________________________________________ Date _____/_____/______ Organization’s Name (if applicable) Parent/Legal Guardian: (if nominator is a minor in his/her state of residence) ___________________________________ Street Address (No P.O. Boxes Please. Include Apt./Ste. if applicable.) ________________________________________________________ City___________________ State ______ Zip Code _____________ www.smharveyfoundation.org SECTION E: Nominator’s Questions (to be completed by the nominator). (If you are nominating yourself, please skip to SECTION F.) 1) Why should your nominee be chosen to participate in The Steve Harvey Mentoring Program For Young Men? 2) What value do you anticipate he will get out of the experience? 3) How do you anticipate it will affect his future? SECTION F: Reference (should be an ADULT, non-‐family member that knows the nominee through community activity {e.g., church, school, volunteering, after school program}. Reference MUST BE someone other than the nominator) Reference’s Printed Name: ______________________________________ Reference’s Daytime Phone Number: ______________________________ Reference’s E-‐Mail Address:___________________________________________ Organization Name / Title: _______________________________________ Relationship to Nominee: _______________________ I hereby certify to the best of my knowledge that the information provided by the nominee and the nominator is accurate. Street Address (No P.O. Boxes Please. Include Apt./Ste. if applicable.) ________________________________________________________ City___________________ State ______ Zip Code _____________ Mail the completed Nomination Form via first-‐class mail to: The Steve Harvey Mentoring Program For Young Men-‐ Chicago, P.O. Box 52817, Atlanta GA 30355 www.smharveyfoundation.org