New Youth Application

New Youth Application

Thank you for your interest in our mentoring program. Please complete this application to begin enrollment into the program. All information collected on this application will be kept confidential within the mentoring program.
Name of Person Completing the Application
First Name*
Last Name*
Your E-mail
example@example.com
Are you the parent or guardian?*
Youth Details
First Name*
Middle Name
Last Name*
Suffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City*

Street Address

Street Address Line 2

State / Province

Postal / Zip Code
State*
Postal/Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do they live in?*
Phone Number*
What is the youth's date of birth?*

MonthDayYear
Date
What is their gender?*
What is their race/ethnicity?*
How did you hear about us?*
Please Specify
What type of school does the youth attend?*
Current Grade Level*
Current School*

Home and Family
Primary Guardian *
First Name
Primary Guardian*
Last Name
Relationship to youth*
What is the primary guardian's date of birth?*

MonthDayYear
Date
Primary Guardian's Phone Number*
Primary Guardian's Email Address*
example@example.com
What is the primary guardian's gender?*
Primary Guardian's Race/Ethnicity*
What is the primary guardian's sexual orientation?
What is the primary guardian's marital status?*
How many children does the primary guardian have?*
Who is the primary guardian's employer?
What is the primary guardian's occupation/title?
What is the primary guardian's highest level of education?*
Has a parent/guardian ever been in prison or jail?*
What parent/guardian was in prison or jail?*
Was the incarcerated parent/guardian in prison/jail due to drug related crime?*
Can you tell me about the relationship between the youth and the incarcerated parent?
Has the youth ever been homeless?
Does the youth live in a single caregiver home? If no, leave blank.
Has the youth ever been involved in foster care?
Has the youth ever been exposed to illegal substances/drugs?*
Has the youth ever been involved with the police/juvenile justice system?*

Medical
Does the youth have any allergies?*
Please explain.
Does the youth take any medication?*
What medication?
Relationship to you
Does the youth have any physical limitations?*
What is the youth's health insurance carrier?*
What is the youth's health insurance policy number?*
Can you provide an emergency contact?*
First and Last Name
What is their relationship to the youth?
Phone Number*
Can you provide an additional emergency contact?*
First and Last Name
What is their relationship to the youth?
Phone Number*

Release of Information
What is the youth's first and last name?*
What is the youth's date of birth?*

MonthDayYear
Date
Media Release:

Knoxville Leadership Foundation (KLF) and its programs or various other media may choose to take pictures or videotape participants during events and activities. These images may be used for KLF displays, brochures, newsletters, archives, news releases, publicity and Web sites. I hereby grant permission to Knoxville Leadership Foundation to take and reproduce photographs and videotapes for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by Knoxville Leadership Foundation.
Do you agree to the media release?*
School Release:

I hereby authorize Knox County Schools to disclose school records that include grades and/or academic transcripts, attendance records, and disciplinary records to KLF employees and support staff.
Do you agree to the school release?*
Release of Information to Potential Mentors:

I hereby authorize KLF and potential mentors to exchange the following information:

General family information and history; interests; academic information; medical and mental health history; etc. (any other pertinent information to assist in matching my child with a mentor).
Do you agree to the release of information to potential mentors?*
Juvenile Records Release

I hereby authorize KLF and Knox County Juvenile Court to exchange the following information:

Juvenile court records, criminal history records, case planning notes and progress notes to assist in evaluation and matching.
Do you agree to the juveniles record release?*
Should be Empty:

New Youth Application

Home and Family

Medical

Release of Information