Youth Mentor Program Youth Information First Name Last Name Gender Male Female Date of Birth Age Address City Postal Code Cellphone Number Home Phone Number Email Address Is the youth currently attending school? Yes No Current School Grade Languages Spoken Families Cultural Background Do You Need An Interpreter? Yes No Which best applies to the youth Citizen Permanent Resident Refugee Other Specify if other Does the youth identify as a Newcomer? Yes No Is the youth on any medication that we need to be aware of? Yes No If Yes, describe Any allergies? Yes No If Yes, describe Does the youth have any emotional, mental, physical, or specific medical health conditions that we should know about? Yes No If Yes, describe Is the youth in counseling or receiving services from Child Protective Services? Yes No If Yes, describe Is the youth or family currently involved with Child Protective Services? Yes No What is the level of Involvement? Family Enhancement Protection office location Phone Number Social worker’s name: Emergency Contact Information Contact Name Relationship Phone No.1 Phone No.2 Parent/Guardian Information where applicable and youth ages 12 - 17 Years old Parent/Guardian's First and Last name Relationship Phone Number Email Address Languages Spoken Do you need an interpreter? Yes No Other Parent/Guardian(s) Name(s) if any Relationship Phone Number Getting to know the youthThis will help us with matching the youth with a compatible mentor Why does the youth need/want a mentor? Tell us about the youth’s personality and strengths What would you say are some of the youth's challenges? Is there anything you would like us to be aware of that would assist us in finding the right mentor for the youth? Yes No If yes, please describe List some of the goals/changes the youth would like to achieve while in the program. This could either be academic, social, and personal skills, cultural connection, professional development, networking, communication skills, leadership skills, or other skills. How did you hear about this program? Select all that applies. The Academy Builders social media The academy builders email newsletter word of mouth other Specify if other By ticking on the checkbox bellow, you consent to receive services from The Academy builders I agree to the terms mentioned above Complete Name ReferralTo be completed by the referring Agency only Referring Agency Referred By Phone Number Email Address Send
