Referral Application

Individual Information
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Phone
Email
example@example.com
Guardian/Parent Information
Guardian/Parent Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
Email*
example@example.com

Education
School Name*
Address*
Grade*
General Information
Gender*

MaleFemaleOtherDecline to Respond
Ethnicity*
What are your religious preferences*
What is your primary language*

Family Contacts/Role Models/Mentors
Name*

First NameLast Name
Relationship*
Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name*

First NameLast Name
Relationship*
Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Can the individuals listed above be used as emergency contacts?*

YesNo
Medical
Does the individual have any allergies*

YesNo
If yes, please describe
Does the individual have any physical health/medical conditions or disabilities*

YesNo
If yes, please describe

Medium Risk
Beginning stages of trying drugs and alcohol*

YesNo
If yes, please describe
When did usage start
Was there an event that triggered the beginning of usage?

YesNo
High Risk
Regular drug and alcohol usage*

YesNo
If yes, please describe
Trouble with the law/legal issues*

YesNo
If yes, please describe.
Guardians Goals/Expectations
Goals/Expectations #1*
Goals/Expectations #2*

Release of Information
I hereby authorize:
School/Organization*
School/Organization Address*

Address

Street Address Line 2

CityState

Zip Code
To release all school records including courses and grades, test results, written evaluations, ongoing writtne and verbal exchanges, attendance records, health records, and educations plans to:

Destination Elevation

PO Box 203

Mandan, ND 58554
Meeting with Mentor

I recognize that for a mentor to work with my child, I will need to maintain contact with the assigned mentor and understand the mentor and I will need to set designated times for the mentor to meet with my child. *Mentor and mentee dates and times will be determined by the parent/guardian and the mentor*

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
Guardian Signature*

Clear
Date*

MonthDayYear
Date
Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: