If you need to refer someone to our mentoring program, please fill out the following form.
Youth's First Name
Youth's Last Name
Birth Date
Age
Gender MaleFemale
Name of School
Grade
Street Address
City
Province
Postal Code
Parent/Guardian Name
Relationship to youth (Mother, Father, Other: Please specify)
Phone Number
Name of Referent
Your Email
Your Phone Number
Why do you think this youth would benefit from the SCCYI Mentoring Program?
Describe the youth (personality, strengths, etc.)
Useful strategies for working with this youth:
Medical concerns that the Mentoring Program should be aware of (allergies, medications, etc.)
Additional Comments:
