Alonzo F. Herndon Game Changer
Entrepreneur Program
APPLICATION
A PROGRAM OF THE ALONZO F. AND NORRIS B. HERNDON FOUNDATION
Page 2
TABLE OF CONTENTS
1) Introduction
A) About the Alonzo F. and Norris B. Herndon Foundation
B) About the Alonzo F. Herndon Game Changer Program
C) Dates to Remember
2) Your Life
A) Personal Data
B) Family Information
C) Academic Honors
D) Extracurricular Honors
E) Volunteer and Extra Curricular Activities
3) Your Outlook – Essay Questions
A) Entrepreneurial Experience Essay
B) The Herndon Legacy Essay
4) Authorizations & Agreements
A) Student Consent
B) Release and Indemnification
C) Parent/Legal Guardian Agreement Signatures
Page 9:
Page 10:
Attachment One: Nomination Form
Attachment Two: Counselor Verification
APPLICATION INSTRUCTIONS


Students, please complete the following application to the Alonzo F. Herndon Game Changer
Entrepreneur Program with your parent.
Then, submit your portion of the completed form via email or postal mail to:
[email protected]
Herndon Game Changer Program
Attn: Julissa White
587 University Place, NW
Atlanta, Georgia 30314
Telephone: 404-581-9813


Ensure your principal, counselor or teacher completed the nomination form (found on page 9)
Ensure your counselor receives/completes the counselor verification form (found on page 10)
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1 INTRODUCTION
A. About the Alonzo F. and Norris B. Herndon Foundation
The mission of the Foundation is to advance The Herndon legacy by educating, mentoring, and
equipping the next generation of entrepreneurs, while fulfilling a vision to instill an entrepreneurial
mindset in tomorrow’s leaders. Incorporated in 1950 as a non-profit corporation to be used
exclusively for religious, charitable, scientific, literary, and educational purposes, the Foundation has
been a major benefactor to Metro-Atlanta institutions and organizations supporting the cause of
economic and social development associated with the civil rights movement. Today, the Foundation
continues to support a number of charitable endeavors and programs, designed to stoke the same
entrepreneurial dedication exemplified by the Herndon legacy.
B. About the Alonzo F. Herndon Game Changer Program
The Alonzo F. Herndon Game Changer Entrepreneur Program is project-based program designed to
foster the development of a community-based business idea where a comprehensive business
presentation is the finished product. Student teams will participate in several educational and
interactive instructional sessions which mirror the segments of a detailed business plan over the
course of eight months, leading up to the final business presentation and graduation ceremony.
Completing this process allows student participants to see the course concepts applied to one
another’s ideas and community challenges, and brings the content together to provide a holistic, realworld view of how the business planning process works for entrepreneurs.
C. Dates to Remember
September 16, 2016
Due 5:00 p.m.
September 23, 2016
October 1, 2016
Via letter, email, or phone
10am-12:30pm; 12:30pm-1pm lunch
October 8, 2016
November 12, 2016
December 10, 2016
January 14, 2016
January TBD
February 11, 2016
March 11, 2016
March 25, 2016
April 8, 2016
May TBD
May 13, 2016
10am-12:30pm; 12:30pm-1pm lunch
10am-12:30pm; 12:30pm-1pm lunch
10am-12:30pm; 12:30pm-1pm lunch
10am-12:30pm; 12:30pm-1pm lunch
TBD; lunch provided
10am-12:30pm; 12:30pm-1pm lunch
10am-12:30pm; 12:30pm-1pm lunch
10am-12:30pm; 12:30pm-1pm lunch
10am-12:30pm; 12:30pm-1pm lunch
TBD; snacks provided
10am-1pm; reception to follow
Completed Applications and Signed Consent
Forms Due
Selected Students Notified
Orientation for Students and Parents; Pre
Assessment Surveys
Session One
Session Two
Session Three
Session Four
Tour of Atlanta Life Financial Group
Session Five
Session Six
Service Project
Session Seven
Graduation Rehearsal; Post Assessment Surveys
Achievement & Graduation Ceremony
Fall 2016 Application Deadline: 5:00 p.m. EST, September 16, 2016
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2 YOUR LIFE
A. Personal Data
Legal Name: Please enter your name (Last, First, Full Middle) Here
Last Name
First Name
Email Address: Please enter your full Email address here
Permanent Home Address: Please enter your home address here
Street
(suite/ apt. #)
Primary Phone Number: ______ - _______ - ____________
Birthday: (mm/dd/yyyy)
Are you a U.S. Citizen?
YES☐
NO☐
T- Shirt Size (Check one)
Women
-XS☐
Men
-XS☐
Name of School: Click or tap here to enter text.
School Address: Click or tap here to enter text.
Street
City
-S☐
-S☐
City
Middle (Full)
State
-M☐ -L☐
-M☐ -L☐
County
Zip code
-XL☐ -2X☐ -3X☐
-XL☐ -2X☐ -3X☐
Zip Code
What will be your grade level in Fall 2016? Sophomore ☐
Junior ☐
Senior☐
What is your grade point average (G.P.A)? _________
What is your anticipated date of graduation? _________
Have you ever been suspended or expelled from school? YES ☐
NO ☐
If yes, please explain:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What are your plans after high school graduation?
Four-Year College☐ Two-Year College ☐ Trade School ☐ Work/Military☐ Unsure ☐
Describe your career or professional plans:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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B. Family Information
Parent/Guardian 1: ____________________________
Full Name: ___________________________________
Mother ☐
Father ☐
Legal Guardian ☐
Parent/Guardian 2: ____________________________
Full Name: ___________________________________
Mother ☐
Father ☐
Legal Guardian ☐
Home address if different from student:
Home address if different from student:
Home Phone: ______ - _______ - ____________
Cell Phone: ______ - _______ - ____________
Email Address 1: ____________________________
Email Address 2: ____________________________
Home Phone: ______ - _______ - ____________
Cell Phone: ______ - _______ - ____________
Email Address 1: ____________________________
Email Address 2: ____________________________
___________________________________________________________________________
Street (suite/ apt. #)
City
State
Zip code
___________________________________________________________________________
Street (suite/ apt. #)
City
State
Zip code
With whom do you reside permanently?
Parent /Guardian 1 ☐
Parent/Guardian 2 ☐
Both ☐
Other ☐
*If you selected other, please provide their information below
Full Name: _______________________________________________________________
Home address if different from student: _______________________________________________________________________
Street
Home Phone: ______ - _______ - ____________
Email Address 1: ____________________________
(suite/ apt. #)
City
State
Zip code
Cell Phone: ______ - _______ - ____________
Email Address 2: ____________________________
Fall 2016 Application Deadline: 5:00 p.m. EST, September 16, 2016
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C. Academic Honors: List and briefly describe any scholastic distinctions received.
i. ________________________________________________________________________________________
______________________________________________________________________________
ii. ________________________________________________________________________________________
______________________________________________________________________________
iii. ________________________________________________________________________________________
______________________________________________________________________________
D. Extracurricular Honors: List and briefly describe any extracurricular distinctions received.
i. ________________________________________________________________________________________
_____________________________________________________________________________
ii. ________________________________________________________________________________________
______________________________________________________________________________
iii. ________________________________________________________________________________________
______________________________________________________________________________
E. Volunteer and Extra Curricular Activities: List and briefly describe your extracurricular
activities, volunteer service, or other projects/organization you have been involved.
Activity/Service/Project/Organization
Position held/Year(s)
Responsibilities
involved
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
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3 YOUR OUTLOOK
The following section includes two short essay questions. Please print your responses on the lines
provided.
Entrepreneurial Experience: Please describe any exposure or experience you have had with
entrepreneurship? (max 200 words)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
________________________________________________________________________________________________________
The Herndon Legacy: How does the life of Alonzo F. Herndon serve as an influence for modern day
entrepreneurs? (max 200 words)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Fall 2016 Application Deadline: 5:00 p.m. EST, September 16, 2016
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4 AUTHORIZATIONS & AGREEMENTS
A.
STUDENT CONSENT
I understand that, as a participant in the Alonzo F. Herndon Game Changer Entrepreneur Program, I
have the responsibility to work to the best of my ability in the program; that I will attend every session
and complete the program requirements; that I will conduct myself appropriately and follow all rules,
regulations and policies of the Game Changer Program; that I will support the efforts of Game Changer
staff and participants to preserve the cleanliness and beauty of the host campus; that I will respect the
property of others; and that I will respect the rights and privileges of all Game Changer Program
students, faculty, staff, and others of the host campus community. I understand that failure to comply
with the above may lead to dismissal from the program.
Student Name (Print): _______________________________________________
Student Signature: ________________________ Date: ____________
B.
RELEASE AND INDEMNIFICATION
I hereby grant permission for my child to participate in the Alonzo F. Herndon Game Changer
Entrepreneur Program. I hereby agree to hold harmless and release the Alonzo F. and Norris B.
Herndon Foundation, Inc., its officers, trustees, agents, students, and employees (“Release") from any
claims of damage arising from my child’s participation in the program. I have signed this release with
full recognition and appreciation of the risks of such activities, including risks associated with
transportation to and from the program. I understand that the Herndon Foundation has no medical
personnel during the Game Changer Program and on trips.
I agree that Herndon Foundation personnel assigned to the Game Changer Program are granted
permission to authorize emergency medical treatment if necessary and that such action by persons
shall be subject to the terms of this release. I understand that releases assume no responsibility for any
injury or damage that might arise out of or in connection with such emergency medical treatment. I
further agree that this consent and release shall be construed in accordance with the laws of the State
of Georgia. If any term or provision of this consent and release shall be held illegal unenforceable or in
conflict with any law governing this consent and release, the validity of the remaining agreement, and
portions shall not be affected. I further state that I am the participant’s Parent/Guardian, and am fully
competent to execute this consent and release for full, adequate and complete consideration fully
intending for myself and for my family to be bound by the same.
Parent/Guardian Name (Print): _______________________________________________
Parent/Guardian Signature: ________________________ Date: ____________
C.
PARENTAL/LEGAL GUARDIAN AGREEMENT:
I understand that it is my responsibility to make sure that my child follows Game Changer Program
rules and regulations. I understand that if he/she fails to follow Game Changer Program rules and
regulations, he/she will be dismissed from the program.
_____Parent Initials
We have read and understand the above consent and release statement and agree to the program’s
policies and procedures. I also authorize Game Changer Program representatives to utilize videos and
photographs of my child for Game Changer Program marketing and promotional materials.
_____Parent Initials
Parent/Guardian Name (Print): _______________________________________________
Parent/Guardian Signature: ________________________ Date: ____________
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ATTACHMENT ONE: COUNSELOR VERIFICATION
Dear Counselor,
Thank you for assisting in the application process for the Herndon Game Changer Program.
The student, __________________________________ (print student name) has been nominated, and
completed his/her portion of the Alonzo F. Herndon Game Changer Entrepreneur Program
Application. Within the student has quoted his/her current GPA, classification and
enrollment at your school.
Please confirm this information by filling out the section below (please complete in print) and
returning it to our offices via email to [email protected]. Feel free to email or call
me if you have any questions.
School Name: ___________________________________________________________________
Current Classification: Choose your current class.
Current GPA: __________
Name of School Counselor: ____________________________________________________
Counselor Signature: _________________________________________ Date: ____________
Julissa White, Program Manager
[email protected]
Herndon Game Changer Program
Attn: Julissa White
587 University Place, NW
Atlanta, Georgia 30314
Telephone: 404-581-9813
Fall 2016 Application Deadline: 5:00 p.m. EST, September 16, 2016
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ATTACHMENT TWO: NOMINATION FORM
Who can nominate a student?
Any principal, guidance counselor, or teacher from a Metro-Atlanta high school can nominate
a 10th – 12th grade student to participate in the Alonzo F. Herndon Game Changer
Entrepreneur Program.
Who should I nominate?
Nominated students should be in good academic standing at the school and should display
untapped or undeveloped potential
How to nominate a student:
Complete this form for each student nominee and send your completed form via email to:
Julissa White, Program Manager
[email protected]
Nominee Details
Students Full Name:
Students Current Classification:
Click or tap here to enter text.
Click or tap here to enter text.
School Name: Click or tap here to enter text.
School Address (including zip code): Click or tap here to enter text.
School Phone Number: Click or tap here to enter text.
Nominated By:
Your Full Name:
Title:
Click or tap here to enter text.
Click or tap here to enter text.
School Name: Click or tap here to enter text.
School Phone Number: Click or tap here to enter text.
Your Direct Phone Number: Click or tap here to enter text.
Your Email:Click or tap here to enter text.
Fall 2016 Application Deadline: 5:00 p.m. EST, September 16, 2016
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