Form
Group Mentoring Child and Teen Application 2026-2027
Heading
Child and Teen Group Mentoring Applications
I'm registering this child for:
Elementary Age Group Mentoring (ages 6-11)
Teen Group Mentoring (ages 12-14)
Child's Name
First Name
Last Name
Child's Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's preferred name on mentoring nametag
Child's Gender
Please Select
Male
Female
Other
Child's Birthdate
Child's Current Age
Child's Primary Language
Child's t-shirt size
Please Select
Child's small
Child's medium
Child's large
Adult small
Adult medium
Name of Caregiver
Relationship to Child
Caregiver's Primary Language
Caregiver's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver's Email
example@example.com
Child is living with:
Is your child assigned to a Caseworker?
Please Select
Yes
No
To help us share information about our program, please share your child's assigned Caseworker's name, phone number and email information:
Names of child's siblings attending mentoring (please remember each child needs a completed application done):
What are the two most important aspects we should know about your child that would help us best serve him/her in group mentoring?
Please explain any unusual family circumstances that make group mentoring important for this child (i.e. recent crisis, severe neglect, foster placement etc.)
Please list child's allergies
Any illnesses and/or hospitalization for medical or psychiatric reasons in the last year for this child? If yes, please explain.
Please Select
No
Yes
Explain:
Does this child use any assistive devices (hearing aids, leg/arm brace etc.)? If yes, please explain.
Please Select
No
Yes
Explain:
Please list prescription and over the counter medications your child is taking:
Caregiver's Signature
Submit
Should be Empty: