Mentee Referral Form

Thank you for referring a youth to The Center's mentoring program. If you are a parent or guardian, please do not fill out this form, instead complete the mentee application form alongside the youth.

This form is for referring youth between the ages of 10-16 who live in Swift Current to The Center's mentoring program. Exceptions may be made for youth outside this age range and location, just know the chance of being matched with a mentor may be lessened.

We aim to create long-term, supportive relationships between youth and mentors, empowering youth to develop life skills and become positive members of society. Please fill out the form below as best as you can to help us understand the youth's needs and how they could benefit from this program. Youth's First Name Youth's Last Name Date of Birth Age Gender Name of School Grade Street Address City Province Postal Code Parent/Guardian Name Relationship to youth (Mother, Father, Other: Please specify) Phone Number Parent/Guardian Email Is the parent/guardian aware their youth is being referred to the mentoring program at The Center? Your Name Your Email Your Phone Number Please describe your relationship to the youth. What role you play (social worker, teacher, etc.) and how you interact with the youth (weekly at soccer practice, home room teacher, social worker of 6 years, etc.) Why do you think this youth would benefit from the SCCYI Mentoring Program? What specific areas would you like to see the mentor focus on with the youth? (building self-confidence, schoolwork, getting outside, decision making, etc.) Are there any specific qualities or characteristics that you believe would be helpful for the mentor to have? Describe the youth (personality, strengths, interests, etc.) What are some useful strategies for working with this youth? Are you aware of challenges going on at home, school or elsewhere, that might impact their well-being? (Parents divorcing, sibling with substance addiction, financial struggles, bullying, etc.) Are there any medical concerns that the Mentoring Program should be aware of (allergies, medications, etc.) Please provide any additional comments or information that would be beneficial for the mentoring team to know: Input this code: