The Governor's Council on Physical Fitness, Health & Sports, and the Michigan Fitness Foundation

Walk to School Programs

Mentoring: A Running Start

Program Registration Form

Application is to be completed by the adult mentor. All communication with the team will be done through the mentor.

Mentor Information

*First Name	*Last Name

*Home Address

*City	*State	*Zipcode
		(Michigan Residents Only)

*County

*Evening Phone	Day Phone	Cell Phone

*Please send updates to the following email address:

I don't have an email address. Please send updates to my home address.

*Gender	*Date of Birth	Race (optional)
Male Female
	(mm/dd/yyyy)

Mentor Work Information

*Organization
*Address
*City
*State
*Zipcode

Mentor Optional Information:

Which of the following health-related goals are you hoping to achieve by participating in this program? (mark all that apply)

	Weight Management
	Lowering Blood Pressure
	Reducing Cholesterol
	Eat Healthier

	Managing Type 2 Diabetes
	Increasing Energy Levels
	Reducing Stress

Other:
None of the Above

Mentee Information

*First Name	*Last Name

*Address

*City	*State	*Zipcode
		(Michigan Residents Only)

*County

*Evening Phone

*School Attending

*Gender	*Date of Birth	Race (optional)
Male Female
	(mm/dd/yyyy)

Mentee Legal Guardian Info

*Legal Guardian Name
*Legal Guardian Home Phone
*Legal Guardian Office Phone
*My child (listed above) is eligible to receive free or reduced priced school meals	Yes No

Mentee Optional Information

Which of the following health-related goals are you hoping to achieve by participating in this program? (mark all that apply)

	Weight Management
	Lowering Blood Pressure
	Reducing Cholesterol
	Eat Healthier

	Managing Type 2 Diabetes
	Increasing Energy Levels
	Reducing Stress

Other:
None of the Above

Additional Team Information

*Name of Mentor Organization

*Please provide the name(s) and contact information (email address and telephone number) for your caseworker, a representative of the mentoring organization with which you are affiliated or others who work with you in connection with mentoring.
*Is your involvement in mentoring connected with a mentoring program at your place of employment? Yes No
If yes, please list the organization, the name of their mentoring program, the name of the person managing the program and their contact information
*(Mentor Response) Please provide an explanation of why you would like to be selected for this opportunity
*(Mentee Response) Please provide an explanation of why you would like to be selected for this opportunity
* I acknowledge that my online application is complete and I agree to submit the signature page
*As part of the Mentoring: A Running Start* program, I understand:** * That if selected, I commit to appropriately training with my mentee for participating in a 5K (3.2 mile) race * That during the race I must stay with my mentee at all times * That rooming assignments will be made with two mentors sharing a room and mentees, matched by age and interests, sharing a room. The reason for the pairing is because:
It is consistent with Michigan Fitness Foundation policy Chaperones are available 24/7 to assist with supervising mentees Experience with this program shows that mentors appreciate a break This allows for and fosters bonding time between participants, especially the mentees
* That there will be an orientation for the program in April or May and I will make every effort to participate in person (in Detroit or Lansing locations) or by phone