Mentee Application Non-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* Where did you learn about Youth Assisting Youth 1-to-1 Mentoring Program?*: Other*: What is your official language of preference?*: Reason for Referral - Social Concerns*: Reason for Referral - Behavioural Concerns*: Reason for Referral - Emotional Concerns*: Reason for Referral - Trauma Concerns*: Reason for Referral - Other Please select the following that best describes the child*: 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: 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)*: If Guardian, please note relationship to child: Will an interpreter be needed?*: Interpreter - Language*: Can we contact the parent/guardian at work?*: Please tell us where the parent/guardian is employed and at what number they can be reached during work hours*: What is the legal/court order regarding the child above?: Other*: Are there any other legal/court provisions that we should be aware of? (e.g., restraining order)*: Please explain*:

Emergency Contact Information

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

Other Parent Information

Only answer this section if you have joint custody of the child

Other Parent - First Name: Other Parent - Last Name: Other Parent Address - Street: Other Parent Address - City: Other Parent Address - Province: Other Parent Address - Postal Code: Other Parent - Home Phone (Please use this format: 4169321919): Other Parent - Cell Phone (Please use this format: 4169321919): Other Parent - Email*: If not living at the same household, does the child visit the other parent?: How Often*: Is the other parent aware of this application to the program?: If there are any additional notes/comments you would like to make please make them in the box below:

Family Relationships

Please write the name 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: Please give a brief description of the family: (i.e., cohesiveness, supervision, difficulties, etc.)*:

Medical History

Any Medical Concerns or Allergies*: Explain*: On Medication*: Please write down name and dose of the medication(s): Does the mentee know how to administer their medication on their own?:

School Information

School Name*: School Address - Street*: School Address - City*: School Address - Province*: School Address - Postal Code*: School Phone Number*: Grade*: Is the child interested or active in (select as many as applies)*:

Referring Source (Referring Workers Only)

In this section, we ask for some basic information about the Referring Worker that is making this referral

Referring Worker Name*: Agency/Organization and Title*: Phone (Please use this format: 4169321919)*: Phone Extension: Referring Worker - Email Address: How long have you worked with the mentee?*: Will there be any follow-up after the referral regarding the mentee?*: Date of Referral*: What level of cooperation do you anticipate between the mentee’s parent(s)/guardian(s) and the volunteer?*: If answered "low" or "medium" to above, please explain*: Is the mentee aware of the application to the Youth Assisting Youth?*: What was the reaction?*: Is the mentee involved with any other community or similar mentoring agency or program?*: Other Community/Agency - Name*: Other Community/Agency - Contact Name*: Other Community/Agency - Phone Number (Please use this format: 4169321919)*:

Consent To Release Information Between Agencies

Have the parent(s)/guardian(s) been informed of the Youth Assisting Youth program and of this referral?*: As the referring worker, I hereby have authorization on behalf of the parent/guardian to refer this child to the Youth Assisting Youth's one-to-one mentoring program*:

ACKNOWLEDGMENT: THE ABOVE INFORMATION IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE.

FOR REFERRING WORKER: I understand and agree with the above "ACKNOWLEDGMENT" statement and accept and understand that selecting "yes, I accept" acts as the legal equivalent to my signature*: As the referring worker, I hereby have authorization on behalf of the parent/guardian to release this information to: Youth Assisting Youth | 5734 Yonge Street, Suite 400 | Toronto, Ontario | M2M 4E7 Any and all information regarding the above named client pertaining to: personality traits, behavioural concerns and special needs for the purpose of: finding a volunteer mentor*: