BCMP Youth Participation Form
Some of the following questions are very personal in nature. These questions will help the program know your child completely and be able to match them with a mentor who will compliment their personality and needs as closely as possible.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birthdate
-
Month
-
Day
Year
Date Picker Icon
Choose One
Male
Female
Ethnicity
Graduation Year
Grade in School
School
Participant's Number
-
Area Code
Phone Number
Guardian's Number
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Participant's E-mail
Guardian's E-mail
Please list all members of your household (gender, age, relationship)
Ex. Levi - Male, 2, brother
Interest Survey
Please check all activities in which you have an interest:
Biking
Camping
Hiking
Boating
Cooking
Reading
Music
Science
Fishing
Swimming
Animals
Movies
Golf
Basketball
Baseball
Football
Soccer
Volleyball
Painting
Photography
Board Games
Shopping
Gardening
Other
Availability
Indicate what times are most convenient to meet:
Check all that apply
Lunchtime (Weekdays)
After School (Weekdays)
Evenings (Weekdays
Mornings (Weekends)
Afternoon (Weekends)
Evenings (Weekends)
Consent
We believe in you and the successes you will encounter through this mentoring experience, and we would like to be able to share with our community the impact you are having in our community.
Will you give consent to the use of any photographs of yourself for promotional purposes? Please answer "yes" or "no" and mark your initials next to your answer (ex. Yes - MW):
Do you believe you are ale to make at least a one-year commitment for the mentoring program? Please answer "yes" or "no" and mark your initials next to your answer (ex. Yes - MW)
Do you believe you are able to meet the minimum 4 hours a month meeting with your mentor? Please answer "yes" or "no" and make your initials next to your answer (ex. Yes - MW).
Parent/Guardian Consent
I give my consent for the Boone County Mentoring Partnership (BCMP) to my child (named above) with an adult volunteer mentor. I will also give consent for my child to participate in BCMP activities; including all organized activities and transportation. In consideration of the advantages of participation in the program, the undersigned agrees that the BCMP, its agents, and its employees shall be released and exempt from any liability for damages for bodily injuries or property damages that may occur as a result of participation in the mentoring program, expect to the extent of insurance liability as provided by the law.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Home Number
-
Area Code
Phone Number
Cell Number
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
E-mail
Emergency Contact
Emergency Contact Phone Number
-
Area Code
Phone Number
Will you be able to help with transportation of your child to meet with the mentor?
Yes
No
On a scale of 1-10 (1 being the least and 10 being the most), how involved will you be in the mentoring program?
Please share briefly why you think your child would benefit from the program and anything that would be helpful for us to know.
Has you child experienced any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details.
Can you provide any additional background information that may be helpful in matching your son/daughter with an appropriate mentor? (Anything that we should be aware of that could be a trigger for you or your child.)
Do you have any religious preferences you would like for us to take into consideration?
Is there anyone your child should not have contact with?
Medical History
Does your son or daughter have any physical concerns or limitations?
Yes
No
Is your son/daughter receiving treatment for any medical issues? If yes, please explain.
Is he/she currently taking any type of medications? If yes, please explain.
Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please explain.
Does your son/daughter have any emotional issues right now? If yes, please explain.
Is your son/daughter currently seeing a counselor or therapist? If yes, please explain.
Please attach a recent photo of the applicant.
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