Youth Referral Form Youth Name* First Middle Last 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 Year of Birth*Please enter a number from 2000 to 2012.Youth Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Youth Cell PhoneYouth Email How Would You Prefer us to Contact You? Phone Email Text All of the above HiddenSocial Media Typecheck all that apply Facebook Instagram Twitter YouTube Snap Chat Other HiddenSocial Media Handle Age Primary Language School InformationCurrent Grade* Middle School High School School* Program Enrollment* RISING - Meany MS RISING-Denny MS RISING-Denny MS (Girls) One-On-One Tutoring Group Mentoring Active-No Program Assignment Inactive Have you ever had a mentor before? Yes No Not sure What kinds of things are you looking for in your mentor? “I want someone who will…” Support me Encourage me Listen to me and understand me Keep me motivated to keep my goals Support me in a drug/alcohol-free lifestyle Support me in a crime-free lifestyle Strengthen my social skills Help me to try new things Other Other Are you willing to commit to this relationship for at least one year? Yes No Do you have a strong desire to improve your life and the life of those around you? Yes No Do you have any goals right now? What are they?Tell us about your family:Give an example of a commitment you have had in life that you were required to do on a weekly basis. How did you do?Do you have any questions about the 4C Coalition mentor program?Are you involved with any other programs or agencies that have been helpful to you?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 What is your level of interest in the activities listed below?StrongSomeNoneNature/OutdoorsPlaying Online GamesVideo GamesOnline SchoolWalkingWriting/JournalingDancingColoring/PaintingHiking/ExploringListening to MusicMusical InstrumentsPuzzlesHoliday ActivitiesPets/AnimalsMoviesShows/SeriesVisiting with friendsSocial MediaPartiesTravellingWhat is your level of interest in the activities listed below?StrongSomeNoneCampingOutdoor SportsIndoor SportsFashionShoppingDatingHanging with friendsHanging with familyExercisingSingingDecoratingPhotographyScienceGardening/Yard workSchool Sports - PlaySchool Sports - WatchGoing out to eatCooking/BakingTalking on the phoneTextingEmailThis field is for validation purposes and should be left unchanged.
