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YOUTH MENTORING OF THE SOUTHERN TIER YOUTH APPLICATION AND PARENT/GUARDIAN PERMISSION FORM
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Parent/Guardian Name:
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Relationship to Youth:
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Youth's First and Last Name
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Youth's Gender:
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Youth's Preferred Name/Nickname:
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Home Address
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City/State/Zip:
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County:
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What is the Child's Living Situation?
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Two-Parent Household
One-Parent Household
Foster Home
Group Home
Other Relative of Youth (non-parent)
Other
Other
Home Phone Number:
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Parent/Guardian Cell Phone Number:
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Parent/Guardian Email:
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Youth's Email:
Preferred Method of Contact:
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Phone
Email
Text
Youth's Age
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Youth's Date of Birth
*
Grade
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School
*
Child's Race/Ethnicity:
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American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Multi-Race
Other
Other
Parent/Guardian Place of Employment:
Parent/Guardian Work Phone Number:
May we contact you at this number?
Yes
No
Emergency Contact Name:
*
Relationship to Youth:
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Emergency Contact Phone Number:
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Does Parent/Guardian Receive Income Assistance?
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Yes
No
Is Your Family Considered Low-Income?
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Yes
No
Does Your Child Receive Free or Reduced Lunch?
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Yes/Free
Yes/Reduced
No
Please Check Your Estimated Household Income:
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$0 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 - $30,000
$30,001 - $50,000
$50,001+
What program/location is the youth being referred for?
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Corning
Bath
Elmira
Whitesville Central School
Within the last year, has your child experienced any of the following?
Poor Grades
Skipping School/Classes
Truancy
Behavior Problems
School Suspension
Expelled from School
Sent to an Alternative School
If applicable, please describe any behavior problems, reasons for school suspension or expulsion, or reasons for being sent to an alternative school.
What strengths does your child have that a mentor might be able to help grow?
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What are some of the needs your child has (e.g. emotional, behavioral, or academic) that a mentor may be able to help them with?
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How would you describe the best mentor for your child?
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Does your child have any medical conditions (including food allergies) that might affect his/her participation in activities with Youth Mentoring of the Southern Tier? Please describe.
*