Mentee Application Newcomer - Youth Assisting Youth
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Mentee Application Newcomer

Thank you for your application to Youth Assisting Youth. Please provide your responses below. 

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:

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