• Youth Mentoring Registration Form

    Fill out the form carefully for registration. Youth Mentoring-CCDN has 2 youth mentoring programs. Precious Pearls of Promise (11-18 young ladies) and Diamonds in the Rough (11-18 young men).  Currently, we are meeting virtually every Saturday 12:00 pm-1:30 pm.  When our regular schedule returns the time will change back from 8:00 am-2:00 pm.  
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  • Education and Behavioral Analysis

  • Emergency Persons/Emergency Contacts/Medical Information

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  • NOTE: Please be advised that CCDN will require a copy of the insurance card on file for emergency purposes. 

  • Parent Consent and Certification

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  • NOTE: Any persons designated as an emergency contact or pick up person will be required to show identification prior to picking up the youth.  Parents, please be sure to let them know  A phone call is REQUIRED if there are any changes in pickup person. 

  • I certify that I am a parent/legal guardian of the youth listed in this application.  I give permission for the youth listed in this application to participate in Community Care Development Network programs, services, and sponsored events and activities.  I have read and understood all of the releases above:

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