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What School Do You Attend? *
Grade *
What is the Mentor's Living Situation? *
Child's Race/Ethnicity: *
May we contact them at this number?
The income information listed below is kept confidential and is used anonymously for grant purposes only.
Does Parent/Guardian Receive Income Assistance? *
Does Anyone in Your Family Receive Free or Reduced Lunch? *
Please Check Your Estimated Household Income: *
Is your family considered to be low income? *


Please include the following information for two references. References can include a teacher, school counselor, adult employer, or adult co-worker.
I understand that:
1. The references I listed may be contacted by mail, telephone, or email;
2. I am in no way obligated to perform any volunteer services;
3. Youth Mentoring of the Southern Tier is not obligated to match me with a youthl and 
4. As part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations being made for assignment.
Signature *