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Youth Application

 

Date: Parent/Guardian's Name: Child's Name:
Home Address: City: State: Zip:
Home Phone#: Cell Phone#: Email:
Child's School: Grade:
Parents Employment: Work Phone# Best time to call:
Is the Parent Receiving Income Assistance?: Yes No
Does your Parent/Guardian speak & understand English? Yes No
If no, what is the primary language Youth's DOB: Youth's Gender:

1. What is the primary reason for you wanting your child to have a mentor?
2. Does your child want a mentor? Yes No Youth's Ethnicity:

What is your living situation?

 
Does your child have any medical or mental conditions that might affect his or her participation in activities with a mentor? Yes No
If Yes, please describe:
Does your child have any allergies? Yes No Do you share custody? Yes No
If Yes, are they aware of the child's enrollment in Mentoring Plus? Yes No

Do you anticipate any significant life changes over the next year or have you had any over the past year?

Yes No

If Yes, please explain:
 
Youth's Interests, Skills and Hobbies Checklist
 
Check the box, which best describes how you feel about each of these activities
ACTIVITY
ENJOYS
DISLIKES
LIKE TO TRY
Horseback Riding
Boating
Skiing/ Snowboarding
Board Games
Watching Sports
Playing Sports
Fishing
Reading
Movies
Roller Blading
Sewing
Cooking
Painting
Video Games
Computers
Biking
Crafts
Music
Bowling
Visiting the Library
Going out to Eat
Hiking
Visiting Museums

* Please review form before clicking finish...

 

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