Youth Referral Form "*" indicates required fields Youth Name* First Middle Last Date of Birth* MM slash DD slash YYYY HiddenYear of Birth (do not delete to keep historical submissions)Please enter a number from 2000 to 2014.Age Gender Male Female Self-describes in another way Prefer not to say Race/Ethnicity American Indian/Alaska Native Asian/Asian American Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Multiple races Another race Prefer not to say Unknown Other race Youth Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Youth Cell Phone*Youth Email Primary Language Hobbies and InterestsChoose all that apply Music Sports Reading Gaming Visual Arts (i.e. drawing, designing, …) Dancing Acting Politics Volunteering Earning Money Cooking Other PersonalityChoose all that apply Outgoing Business-Oriented Empathetic Funny Reserved Lively Reflective Passionate Constructive Forward-thinking Shy Intuitive Other School InformationWhat school do you attend?* Meany MS Denny MS Lincoln HS Demmitt MS Nelsen MS Other School* Current Grade* Middle School High School Elementary Program InformationPlease select the program(s) the scholar is interested in enrolling. Enrollment is open for the 2024-2025 School YearHybrid Programs (Online + In-person Events) Boys Group Mentoring (Middle School) Monday Evenings Girls Group Mentoring (Middle School) Monday Evenings Boys Group Mentoring (High School) Monday Evenings Girls Group Mentoring (High School) Monday Evenings One-On-One Mentoring Tutoring (Sunday Afternoon) HiddenAre you interested in the RISING Program (In School)? Meany MS (Boys) Meany MS (Girls) Denny MS (Boys) Denny MS (Girls) Lincoln HS (Boys) Lincoln HS (Girls) Demmitt MS (Boys) – Renton SD Demmitt MS (Girls) – Renton SD Nelsen MS (Boys) – Renton SD Nelsen MS (Girls) – Renton SD I do not go to any of these schools Are you interested in the RISING Program (In School)? Meany MS (Boys) Meany MS (Girls) Are you interested in the RISING Program (In School)? Denny MS (Boys) Denny MS (Girls) Are you interested in the RISING Program (In School)? Lincoln HS (Boys) Lincoln HS (Girls) Are you interested in the RISING Program (In School)? Demmitt MS (Boys) – Renton SD Demmitt MS (Girls) – Renton SD Are you interested in the RISING Program (In School)? Nelsen MS (Boys) – Renton SD Nelsen MS (Girls) – Renton SD HiddenProgram EnrollmentCheck all programs of interest One-On-One Mentoring Group Mentoring Tutoring Have they ever had a mentor before? Yes No Not sure Other Other Parent/Guardian InformationParent/Guardian Name* First Middle Last Parent/Guardian Primary Language Parent/Guardian Phone*Parent/Guardian Email Parent2/Guardian2 Name First Middle Last Parent2/Guardian2 Primary Language Parent2/Guardian2 PhoneParent2/Guardian2 Email Emergency ContactEmergency Contact First Middle Last Emergency Contact PhoneEmergency Contact Email Youth Referral has been completed by: (Name & Relation to youth) CommentsThis field is for validation purposes and should be left unchanged.
