Youth Mentorship Program

Youth Mentorship Program

*Our Transition to Adulthood program helps at-risk youth ages 14-18 graduate from high school, assists them in furthering their education through secondary education or vocational training, supports them in developing critical life skills, and we will continue to offer them food, basic necessities, and clothing as needed. Mentors are available for youth interested in getting a driver’s license, college or post-secondary education plan, getting a job, rent a room or apartment, buy a car, build and maintain a personal budget, paying or planning for taxes when employed, family planning (I want to be a mom or dad), plan a trip, vacation or experience, health and fitness, mental health and well-being, any personal achievement.
This mentorship program is geared towards youth ages 14-18. This mentorship is for youth who are currently involved in our child welfare system. Please take a few moments to fill out this form for your child/children and a volunteer will be reaching out to you within a few days.
Caregiver or Parent's Name # 1 *

Last Name First Name
Caregiver or Parent's Name # 2 (type N/A if not a 2 parent home) *

Last Name First Name
Current Address *

Street Address

City Postal/Zip Code

COUNTY you reside in
Cell Phone Number *

Area Code Phone Number
E-mail *
Are you an (check all that apply) *

Unlicensed Kinship Caregiver (youth with DCS involvement) Licensed Kinship Caregiver (youth with DCS involvement) Licensed Foster Family Tribal Foster Family Guardianship to youth with DCS involvement Non DCS Guardianship Adoptive Family to a child adopted from foster care Licensed Group Home
What events are you interested in learning more about? (check all that apply) *

Jacob's Mission Community Center (after school tutoring, art, dance, piano, guitar, karate, life skills, sports) Foster Hope New Placement Bags filled with essentials Foster Hope Food Box for Families in Need Foster Hope School Backpacks Foster Children's Birthday Party Life Skills Workshops (age 12 and over) such as cooking, framing, electrical, drywall, coding, gardening Jacob's Law Presentation (behavioral health timelines) Clothing from our 24/7 Giving Closet Parent's Night Out for Foster, Kinship & Adoptive Families Family Socials (get to know other families) for Foster, Kinship & Adoptive Families Christmas Event for Foster, Kinship & Adoptive Families Christmas Gifts for Kinship & Foster Families in Need Yearly Couples Retreat Yearly Trauma Mama Retreat Monthly Support Group Volunteering Opportunities Resources and Trainings for Caregivers (Trauma Training, in-the-moment skills, IEP, etc)
Total Number of People Currently Living in the Home? *
Includes all Adults and Children
Total Number of Adults Living in the Home (including children over 18 who are no longer in high school) *
Total Number of Children Living in the Home (including children over 18 who are still in high school) *
Total Number of Children in Foster Care, Tribal Foster Care, or DCS Guardianship Living in the Home (including those 18 and over who are still in high school): *
Kinship is included in this number since they are in the custody of DCS
Total Number of Adopted Children Living in the Home (including children 18 and over who are still in high school): *
Total Number of Biological Children Living in the Home (including children 18 and over who are still in high school): *
Total Number of NON-DCS Kinship or NON-DCS Guardianship Children Living in the Home (including children 18 and over who are still in high school): *
We are required to gather data about the children, youth, and families we werve. The next question will ask if your family falls below following income levels based on household size:

1 person: $20,385

2 people: $27,465

3 people: $34,545

4 people: $41,625

5 people: $48, 705

6 people: $55,785

7 people: $68,865

8 people: $69,945

Add $4270 per additional household member
Based on family size, does your family fall below the income level shown above? (If you are registering a youth in a group home, please click Yes) *

Yes No
How many youth need a mentor? *
How many of the youth needing a mentor are foster children? *
If you have a youth to register click YES and enter their information from youngest to oldest.

Yes I have a foster youth to register

Click HERE to Sign-Up Remaining Children or to Finish Registration
Continue with Sign-Up

Yes, Register my Bio, Adopted, Kinship and/or Foster Children No, I only have Foster Children - Go to Consent and Submit Form

Click Here to Consent
By attending this event, you consent to interview(s), photography, audio recording, video recording and its/their release, publication, exhibition, or reproduction to be used for news, web casts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by ASA Now. Images, photos, and/or videos may be used to promote similar ASA Now events in the future, highlight the event and exhibit the capabilities of ASA Now. You release ASA Now, its officers and employees , and all persons involved from any liability connected with the taking, recording, digitalizing, or publication and use of interviews, photographs, computer images, video and/or sound recordings. By entering the event premises, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, web casting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, web casting, or other publication irrespective of whether a fee for admission or sponsorship is charged. You also waive any right to inspect or approve any photo, video, or audio recording taken by ASA Now or the person or entity designated to do so by ASA Now. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms *

Agree
Liability Release - I do hereby release ASA Now, Jacobs Mission Community Center, their agents, employees, personal representatives, affiliates, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, arising out of or in any way relating to injuries and damages, as a result of being present on Jacobs Mission Community Center property. I recognize that there may be inherent risks associated with attending this event. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms *

Agree
Signature *

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