Mentee Application Newcomer

Apply to Become a Mentee Today!

Thank you for your application to Youth Assisting Youth. Please provide your responses below. To select more than one response, please press and hold the Ctrl or Cmd Key as you click to make your selections.

Email* Please complete this application if the child has a valid immigration status and number (UCI #). The application will not be processed without a valid UCI #. Please complete this application form for children without a valid UCI #*: Where did you learn about Youth Assisting Youth 1-to-1 Mentoring Program?*: Other*: What is your official language of preference?*:

To select multiple items hold "Ctrl" on PC or "Cmd" on Mac as you click your selections

Reason for Referral - Social Concerns*: Reason for Referral - Behavioural Concerns*: Reason for Referral - Emotional Concerns*: Reason for Referral - Trauma Concerns*: Reason for Referral - Other Youth First Name*: Youth Last Name*: Youth Date of Birth (Must be 6 - 15 years old)*: Gender*: Other*: Child's Home Address (Unit/Suite, Street Number, Name i.e. 400 - 5734 Yonge Street)*: Child's Home Address (City)*: Child's Home Address (Province)*: Child's Home Address (Postal Code)*: Is the youth fully COVID-19 Vaccinated?*: Once enrolled in our 1:1 Peer Mentoring Program, participants are eligible to register for the following programs. Please select the program(s) that your child may be interested in: (To select multiple items hold "Ctrl" on PC or "Cmd" on Mac as you click your selections) Parent/Guardian - First Name*: Parent/Guardian - Last Name*: Parent/Guardian - Date of Birth: Parent/Guardian - Email Address*: Parent/Guardian - Mobile Phone (Please use this format: 4169321919)*: Parent/Guardian - Work Phone (Please use this format: 4169321919): If Guardian, please note relationship to child: Will an interpreter be needed?*: Interpreter - Language*: Was the child born in Canada or have Canadian Citizenship?*: What is the date your child arrived in Canada?*: Please provide us with the child's immigration number (UCI #)*: Where was the child born?*: Immigration Status*: Other*: What language(s) does the child speak? (To select multiple items hold "Ctrl" on PC or "Cmd" on Mac as you click your selections)*: Other Languages What language(s) does the parent/guardian speak? (To select multiple items hold "Ctrl" on PC or "Cmd" on Mac as you click your selections)*:

Family Relationships

Please fill in the below information of any other people living in the same household as the child (this can include siblings, extended family, etc)

1st Family Relationship - First Name: 1st Family Relationship - Last Name: 1st Family Relationship - Birthdate: 1st Family Relationship - Gender: 1st Family Relationship - Relationship: 2nd Family Relationship - First Name: 2nd Family Relationship - Last Name: 2nd Family Relationship - Birthdate: 2nd Family Relationship - Gender: 2nd Family Relationship - Relationship: 3rd Family Relationship - First Name: 3rd Family Relationship - Last Name: 3rd Family Relationship - Birthdate: 3rd Family Relationship - Gender: 3rd Family Relationship - Relationship: 4th Family Relationship - First Name: 4th Family Relationship - Last Name: 4th Family Relationship - Birthdate: 4th Family Relationship - Gender: 4th Family Relationship - Relationship:

Emergency Contact Information

Emergency Contact Name*: Emergency Contact Phone Number (Please use this format: 4169321919)*: Emergency Contact Relationship to Mentee*:

Referral Information

This section only needs to be filled out if you are a referring worker from an organization, a health practitioner, or a member of a School Board. If you are the parent/guardian who is filling out this form, please scroll to the bottom of this page and click "submit"

Referring Worker - Agency/Organization: Other*: Referring Worker - Title: Referring Worker - Name: Referring Worker - Phone (Please use this format: 4169321919): Referring Worker - Phone Extension: Referring Worker - Email Address: