Champions of Hope are male high school juniors or seniors who participate in a leadership, philanthropy and service program hosted by Centers for Youth and Families. The Champions of Hope program takes place from September to February.

Congratulations on being nominated to be a Champion of Hope! Centers for Youth and Families Foundation Board of Trustees encourage you to accept this nomination to be a Champion of Hope.

Champions who complete program requirements will: Earn a certificate of recognition. Earn letters of recommendation for college applications and scholarship applications. Be recognized during Evolve: A Modern Day Charity Ball, on Saturday, April 6, 2019 at the

Statehouse Convention Center. Be given three tickets to Evolve.

Please return: A signed Application Form A wallet size or 4 x 6 photo Signed Financial Contract

Champions of Hope application

First Name Last Name M.I. Birthdate

Street Address (inc. Apt#, if applicable)

City State Zip Phone# Email

High School Location (City) Grade GPA

Mom’s Name Dad’s Name

Mom’s Cell Dad’s Cell

Mom’s Email Dad’s Email

Champions of Hope application

Champion of Hope applicant name Signature Date

Parent/Guardian Name Parent/Guardian Signature Date

Program requirements:1. Champions have a commitment of $1,500 to be gifted or raised to benefit boys and girls served by

Centers for Youth and Families. All commitment gifts are invested in programs that help boys and girls overcome trauma and abuse and begin pathways to success. The Centers’ will provide support for fundraising activities.

2. A minimum of $250 is required before or by the Champions of Hope kick-off on Sunday, September 9, 2018. The entire commitment must be completed by April 1, 2019.

3. Each young man completes a minimum of 20 volunteer hours with The Centers for Youth and Families.

4. Champions serve as representatives of their families, schools, peers, and The Centers for Youth and Families, and as models for good behavior, ethics and morals standards.

5. Champions must attend at least 50% of program activities.

Champions of Hope applications must be turned in by Monday, August 27. They can be mailed to The Centers for Youth and Families Foundation, PO Box 251801, Little Rock, AR 72225 or by email at mhendricks@cfyf.org. If you have any questions, you can reach Melissa Hendricks, Foundation Director, at 501-666-9436.

Learn more about The Centers for Youth and Families at:Web site: CFYF.org

Like us on Facebook at: Facebook.com/TheCentersARFind us on Instagram at: Instagram.com/the_centers_ar

Centers for Youth and Families Champions of Hope Financial Commitment

The total tuition of the Champions of Hope program is $1,500, invested in changing the lives of children and youth served by programs at The Centers. A $250 deposit is due by September 9, 2018. The remaining balance of $1,250 must be paid in full by April 1, 2019 or paid by monthly installment through a bank draft.

Any Champions of Hope sponsor must complete a financial contract so we can bill or draft their payments appropriately and provide you with the correct charitable donation credit. Sponsors must complete and sign the following contract. Please contact Melissa Hendricks, Foundation Director, with any changes in the sponsorship plan/payment schedule.

If you chose automatic draft, payments will be:

Deposit of $250 by September 9, 2018 $178.58 October 1 $178.58 November 1 $178.58 December 1 $178.58 January 1 $178.58 February 1 $178.58 March 1 $178.58 April 1

An EFT form is enclosed for your use. If you prefer installments, I will invoice you on September 1, November 1, January 1 and March 1. If you are not current on payments, your son will not be able to participate in activities. If you have a financial sponsor, please provide the following:

Champion of Hope Name:______________________________________________________________

Sponsor Name:______________________________________________________________________

Address:____________________________ City__________________ State____ Zip Code:__________

Total Sponsorship Commitment $________________ which will be paid by: _______________________

_________Automatic Draft from October to April. Enclose a voided check from the account which you wish to be drafted._________I will pay the full payment by check or credit card due by April 1, 2019._________I will pay in installments.

Signature:_________________________________________________________ Date:_____________________

Contact Melissa Hendricks, Foundation Director, at 501-666-9436 or mhendricks@cfyf.org with any questions.

The Centers for Youth & Families, Inc.AUTOMATIC DEDUCTION AUTHORIZATION

Company Name Contact Name _______________________________

Address ___________________________________________________________________________

City/State Zip Code ___________________________________

Phone____________________________ E-Mail ____________________________________

Gift Information:Pledge Amount $________________ Monthly Deduction Amount $______________

Deduction Day: 1st of every month 15th of every month

Fund ___________________________________

Appeal _________________________________

Bank Name

Bank Location (City) (State)

Type of Depositor Account:

Checking (Attach a voided check) Savings (Attach a voided deposit slip)

Bank Transit #:______________________________ Account #: _________________________

AUTHORIZATION FOR AUTOMATIC DEDUCTION

I authorize Centers for Youth & Families to withdrawal funds from my account

Customer Signature Date

NOTE: Staple a VOIDED check/deposit slip to the bottom of this form Your NameAddress

Pay to the order of ___________________________________________________Amount: _________________

__________________________________________________________________________________________________

6789123456789-123456789 _________________________________

Authorization to Photograph, Video Tape, and/or Audio Tape or to Observe

Name:__________________________________________________ Date of Birth_______________

Permission is hereby granted for the following activity(ies) in regard to the above named client (initial all that apply):

____ Photographing ____ Video-taping ____ Audio-taping _____ Use of photograph_____ Observation in publication

This permission is given to Centers for Youth and Families Foundation for the purpose(s) of promoting the Champions of Hope program.

__________________________ _________ _________________________________ ________Signature of Parent/Guardian Date Signature of Champion of Hope Date

CONFIDENTIALITY STATEMENT

I, the undersigned visitor at Centers for Youth and Families, am aware that client privacy is protected by the Health Insurance Portability and Accountability Act. This law specifically forbids me from disclosure of information gained as a result of my visit to The Centers. This confidentiality covers anyone I may see or information I may learn about any client during my visit here.

I confirm that the photographs, video-taped images or audio-tapes will be used only for the purpose identified above.

_________________________ __________ _________________________ ____________Signature of visitor Date Signature of Witness Date

REVOCATION OF AUTHORIZATIONThis authorization may be revoked by notifying Centers for Youth and Families in writing addressed to: Centers for Youth and Families, Attention: Client Records Department, P.O. Box 251970, Little Rock, AR 72225-1970. Protected health information may already have been disclosed before the revocation is received. If so, the revocation will be effective only as of the date it is received by Centers for Youth and Families.