Mental Health Registration Form

Mental Health Registration Form

To Be Completed by the Parent/Guardian
Event Basic Information
Child's Name

First NameLast Name
Parent / Guardian Name

First NameLast Name
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work / Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Youth Date of Birth

MonthDayYear
Date
Youth Gender
Youth Ethnicity
School Name
Grade
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Application Questions
1. Why do you/your child want to participate in a mentoring program?
2. Briefly describe your expectations for the Youthful Generations:
2. Briefly describe your expectations for the Youthful Generations:
3. Is your child available to meet with a mentor eight to twelve hours per month and have contact at least once a week for a minimum of one year? Please explain any particular scheduling issues.

4. Is your child willing to attend an initial youth training session and two training sessions per year after being matched.
5. Describe your child's school performance including grades, homework, attendance, behaviors, etc.
7. Is your child currently having any problems either at home or at school? If so, please explain.
8. Has your child currently experienced any traumatic events (death in the family, abuse, divorce, etc.) If yes, please provide details.
9. Can you provide any additional background information that may be helpful to Youthful Generations in matching you son/daughter with an appropriate mentor?
Medical History
Name of Primary Care Physician: blanks
Phone Number: Area Code Phone Number
Medical Insurance Provider blanks
Policy Number: blank
Phone Number: Area Code Phone Number
Does your son/daughter have any physical problems or limitations?
Is your son/daughter currently receiving treatment for any medical issues?
Is he/she currently on any type of medication? is so, please specify.
Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below:
Is your son or daughter currently seeing a counselor or therapist?
Therapist Name:

First NameLast Name
Type a question
Please read this carefully before signing

Youthful Generations appreciates you and your childs interest in his/her becoming a participant in Youthful Generations Mentoring/Tutoring Program.

After reeiving this completed application from you, we will evaluate the information and send you a confirmation (within 2-3 weeks) letting you know if your child has been accepted into the program. Much of the information you supply in this application will be used to matched your child with an appropriate mentor. Therefore, the mentoring staff may. at times, need access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an intial interest form the youth's parent/guardian, and mentor based first upon anonymous information provided about each other.
Please initial each of the following
I give my consent and permission for my child to participate in the Youthful Generations program and it related activities.
I agree to have my child follow all mentoring program guidelines and understand that any violation on my child's part may result in suspension and/or termination of the mentoring relationship.
I hereby acknowledge that my child will be transported by his/her mentor and/or Youthful Generation staff or representatives while participating in the Youthful Generations Mentoring Program, and such transportations is voluntary and at his/her own risk.
I release the Youthful Generations Mentoring Program of all liability of injury, death, r damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, included but not limited to transportation, and hold harmless any Youthful Generations mentor, program staff or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
(Optional) I agree to allow Youthful Generations to use any photographic image of my child taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
I understand I must return all of the following completed items along with this application, and that any inpomplete information will result in the delay of this application process:
- Contact and Infrmation Release Form
- Interest Survey Form
By signing below, i attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Signature

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Mental Health Registration Form

Event Basic Information

Application Questions

Medical History

Please initial each of the following