This is the youth application form.

This form is for kids and teens to apply to be matched to a mentor. You can also refer a youth or apply to be a mentor.

Some of the following questions are very personal in nature. These questions will help the program know your child completely and be able to match them with a mentor who will complement their personality and needs as closely as possible.

It’s best to complete this form with the child or teen and parent or caregiver together.

This should take about 15-25 minutes. You will need:

A recent photo of yourself
Emergency contact information
Contact information for all participating parties, and
A brief medical history.
We’ll also ask about interests and hobbies.

You can save a copy of this form anytime using the “Save and Continue” link.

Youth application form

Step 1 of 4

25%

Child or teen's information

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Birthdate

MM slash DD slash YYYY

Gender

Ethnicity

Expected graduation year

Current grade

School name

Participant's phone number

Leave blank if there is no number.

Home phone number

Leave blank if there is no number

Participant's email

Leave blank if there is no address

Please list all members of your household including gender, age, and relationship

Now let's talk about interests

Check all the activities you have an interest in

Biking

Camping

Hiking

Boating

Cooking

Reading

Music

Science

Fishing

Swimming

Animals

Movies

Golf

Basketball

Baseball

Football

Soccer

Volleyball

Painting

Photography

Board Games

Shopping

Gardening

Other

You can check all, some, or none. Be specific in the “Other’ category to help us match better.

What's your availability?

Tell us what times are most convenient to meet.

Availability for meeting your mentor

Lunchtime (weekdays)

After school (weekdays)

Evenings (weekdays)

Mornings (weekends)

Afternoon (weekends)

Evenings (weekends)

Don’t worry about summer availability right now. We’ll ask about that later.

Youth consent and legal matters

We believe in you and the successes you will encounter through this mentoring experience, and we would like to share with our community the impact you are having.

Promotional photo sharing conset

I consent to the use of photos of me

I hereby consent and authorize the Boone County Mentoring Partnership to use photographs of myself for promotional purposes. I understand these photos could be shared on social media, websites, and in print in compliance with all applicable laws and regulations.

Time committment consent

I agree I can make a 12-month commitment

I hereby consent and agree that I am able to commit to the program for at least one 12-month period.

Monthly time committment consent

I consent to meeting at least 4 hours per month

I hereby consent and agree I am able to meet at least 4 hours a month with my mentor.

Parent/guardian consent and contact information

Parent's name

First Last

Parent's address

Street Address Address Line 2 City State ZIP Code

Parent's email

Parent's cell number

Parent's work number

Emergency Contact

First Last

This should be a second trusted adult in case we’re unable to reach you in an emergency, like a relative.

Emergency contact's phone number

Will you be able to help with transportation of your child to meet with the mentor?

Yes

Sometimes

Not sure

On a scale of 1-10 (1 being the least and 10 being the most), how involved will you be in the mentoring program?

Please enter a number from 1 to 10.

Please share briefly why you think your child would benefit from the program and anything that would be helpful for us to know.

Has you child experienced any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details.

Can you provide any additional background information that may be helpful in matching your son/daughter with an appropriate mentor? (Anything that we should be aware of that could be a trigger for you or your child.)

Do you have any religious preferences you would like for us to take into consideration?

Is there anyone your child should not have contact with?

Medical history

Does your child have any physical concerns or limitations?

Yes

Not sure (let us know below)

Is your son/daughter receiving treatment for any medical issues? If yes, please explain.

Is he/she currently taking any type of medications? If yes, please explain.

Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please explain.

Does your son/daughter have any emotional issues right now? If yes, please explain.

Please attach a recent photo of the participant

Accepted file types: jpg, jpeg, heic, png, Max. file size: 20 MB.

Make sure your image is clear and you’re the primary subject in the photo.

Parent/guardian consent

I agree to enroll my child in the mentoring program

I hereby agree to the terms of the Boone County Mentoring Partnership and that the information presented on this application is accurate and complete to the best of my knowledge and understanding.

Name

This field is for validation purposes and should be left unchanged.

Apply to be matched to a mentor

Youth application form

Child or teen's information

Now let's talk about interests

What's your availability?

Youth consent and legal matters

Parent/guardian consent and contact information

Medical history