Community Partner Mentee Referral Form
Agency Liasions and Community Partners (ALCP) are the direct link to eligible mentees. L3 partners with ALCPs to refer eligible mentees to the Ladies of Resilience Career Mentoring Program.
Your Name
First Name
Last Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Ext.
Agency/CBC/Community Partner
Agency/CBC/Community Partner Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What region are you in?
Please Select
Northwest
Northeast
Central
Suncoast
Southeast
Southern
County
Mentee Referral
Mentees are in a Child Welfare program, such as, but not limited to: in and out of home care, foster children or Independent Living programs or other at-risk environments such as: homelessness, victims of crime, economically disadvantaged persons, persons with poor mental or physical health, developmentally or physically disabled persons, drug users (in health services), drug offenders (in criminal justice), formerly incarcerated persons.
If you have three or more referrals consider uploading a file (excel, pdf, word) that includes the Parent/Guardian Name, phone, email, include child's name or grade. Multiple children with same Parent/Guardian may be listed seperately or combined e.g. if a guardian had 3 eligible mentees list as: Jane Doe, 555-5545, JD@aol.com, 8th, 8th, 12th.
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1. Referral's Parent/Guardian Name, phone, email, include child's name or grade. Multiple children with same Parent/Guardian may be listed seperately or combined e.g. if a guardian had 3 eligible mentees list as: Jane Doe, 555-5545, JD@aol.com, 8th, 8th, 12th.
2. Referral's Parent/Guardian Name, phone, email, include child's name or grade. Multiple children with same Parent/Guardian may be listed seperately or combined e.g. if a guardian had 3 eligible mentees list as: Jane Doe, 555-5545, JD@aol.com, 8th, 8th, 12th.
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