Next Level Mentoring & Family Services Referral & Application Form

Referral/Application
Date

MonthDayYear
Date
Referring Source
Youth's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender Identity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Name

First NameLast Name
Relationship to Applicant
ie: Mother, Father, Aunt, Uncle, Grandparent, Foster parent
Mobile Number

Area CodePhone Number
Work Number

Area CodePhone Number
Email Address
Number of Siblings
Ages
Ethnicity

WhiteHispanicBlackAsianOther
Name of School
Grade
Average GPA or Letter Grade

Emergency Contact Information

In the event that a parent/guardian cannot be reached, please list person(s) to contact in the case of an emergency.
First Name Last Name Relationship to applicantblank Area Code Phone Number
First Name Last Name Relationship to applicantblank Area Code Phone Number
Does your child have any allergies or medical concerns? Please specify.

Application Questions

Please answer all of the follow questions as thoroughly as possible.
Why do you or your child want to participate in Next Level Mentoring?
Briefly describe your expectations of Next Level through Mentoring.
Is your child available to meet with a mentor at least one hour per week (four hours per month) and have contact at least once a week for the next year? Please explain any particular scheduling conflicts.
Describe your child's school performance, including grades, homework, attendance, behavior etc...
Does your child have friends? Please describe there friendships.
Is your child currently having any behavioral or social problems at home or at school? If so, please provide information that may be helpful for us to know as we work with your child.
Is your child currently dealing with any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details.
Can you provide any additional background information that may be helpful in matching your son/daughter with an appropriate mentor?
Additional Comments
Should be Empty:

Referral/Application