Youth Name
Prefer to Use
Address City State Zip Code
Home Phone Cell Phone E-Mail Address
Birth Date Age
Sex Male Female
Race
School Grade Teacher
Are you adopted? Yes No
Are you your own guardian? Yes No (If you checked no, please fill out parent/guardian information.)
Parent/Guardian Information
MOTHER'S
First M.I. Last
FATHER'S
GUARDIAN'S (If other than parent) Relationship to Child
Youth's Social Security Number
Parent/Guardian's Marital Status: Never Married Separated Divorced Widow(er) Married
Parent/Guardian's Employment Information
Employer Occupation
Work Phone Ext. Fax E-Mail Address
May we call you at work? Yes No
What are you work days and work hours?
If unemployed, what is your means of support?
Miscellaneous Information
Do you or your son/daughter see the absent parent? Yes No If yes, how often?
Do you and the absent parent have joint custody? Yes No If no, who has custody of your son/daughter?
Please list all people currently residing in your home other than you.
Please list other adults (not living with you) that have contact with you or your son/daughter (Relatives, friends, neighbors etc.)
Do you anticipate and changes in your situation? (address, job, family, live-in boyfriend/girlfriend, etc.) Yes No If yes, please explain:
Do you have transportation? Yes No
Are you or your son/daughter, or have you or your son/daughter been under the care of a doctor or counselor? Yes No
Have you or your son/daughter had any contact with the police department? Yes No If yes, please explain:
Describe why you feel you (or your son/daughter) would benefit from a Mentor?
Referred by:
Date Completed:
