Mentee Application Non-Newcomer - Youth Assisting Youth
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Mentee Application Non-Newcomer

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

Email* 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 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: (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)*: 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, to select multiple items hold "Ctrl" on PC or "Cmd" on Mac as you click your selections)*:

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*:

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