MENTORING 4 KIDS (M4K) Parent/Caregiver Intake Form
Thank you for your interest in Mentoring 4 Kids (M4K). This brief intake helps our team learn more about your child, your family's interest in mentoring, and what you hope your child will gain from the program. Fields marked Required must be completed.
Parent/Caregiver Information
Parent/Caregiver Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Mother
Father
Grandparent
Legal Guardian
Foster Parent/Caregiver
Other
Preferred Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Home Address
*
City
*
ZIP Code
*
Preferred Method of Contact
*
Phone Call
Text Message
Email
Preferred Language
*
Please Select
English
Haitian Creole
Spanish
Other
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Current Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Child's School
*
Interest in Mentoring
What prompted you to seek mentoring for your child at this time?
*
What are you hoping your child will gain from having a mentor?
*
A positive adult role model
Increased confidence/self-esteem
Academic encouragement/support
Improved social skills
Emotional support and encouragement
Better decision-making/problem-solving skills
Exposure to new activities and experiences
Career and future planning
Improved communication skills
Positive recreational activities
Greater independence/responsibility
Other
What are some of your child's strengths?
*
Are there any current challenges or areas where you feel your child could use additional support?
Getting to Know Your Child
What activities or interests does your child enjoy?
*
Sports/Fitness
Art/Drawing/Crafts
Music
Dance
Reading/Writing
Gaming
STEM/Technology
Outdoor Activities
Animals
Cooking/Baking
Fashion/Beauty
Movies/Entertainment
Community Service
Faith-Based Activities
School/Academic Activities
Other
How would you describe your child's personality?
*
Outgoing
Quiet
Funny
Creative
Athletic
Curious
Independent
Shy at first
Talkative
Energetic
Calm
Sensitive
Adventurous
Academic
Caring/Compassionate
Other
Is there anything else you would like us to know about your child that may help us better understand and support them?
Mentoring Matching
What qualities would you especially like your child's mentor to have?
*
Are there any qualities, circumstances, or considerations that you would like us to avoid when considering a mentor for your child?
Does your family have any cultural, religious, language, accessibility, or other considerations that you would like M4K to consider when identifying a potential mentor for your child?
*
Yes
No
If yes, please tell us what you would like us to consider.
*
Previous Mentoring Experience
Has your child previously participated in any mentoring program?
Yes
No
Not sure
Please briefly describe the program and your child's experience.
Submit
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