2018 Referral Form

Child / Youth Information

Please read the following information and criteria carefully before completing a referral

Criteria:

Youth who qualify must be in a single parent household, kinship care, or have a parent currently incarcerated. Unfortunately we are unable to accept youth in a two parent household, a youth who is in a 50 / 50 custody arrangement, or one who sees their other parent regularly.

To qualify For SPORTS BUDDIES a youth MUST:

Be between the ages of 8 and 12
Be from a single parent home or kinship care
Qualify for free or reduced lunch at school
Be available 1-2 Saturdays a month for events
The family must have transportation to take the child to and from the events. Unfortunetly this program is not a good fit for families that use public transportation.

To qualify For COMMUNITY MENTORING a youth MUST:

Be between the ages of 9 and 13
Be from a single parent home or kinship care
Qualify for free or reduced lunch at school

Please note:

Unfortunately at this time our waitlist for boys whose family would require a Spanish Speaking Mentor is currently at capacity.
Please discuss the program with the family / guardian first, confirm they are interested, and obtain permission before making a referral.

Child / Youth's FULL Name *

Date of Birth

- Month - Day Year

Child's Age *

Gender *

Ethnicity

Child's School

School District

Grade

Parent / Guardian Information

Parent / Guardian's Full Name *

Relationship to Child *

Phone Number *

- Area Code Phone Number

E-mail

Home Address

City

Zip Code

Does the child qualify or receive free or reduced lunch at school? *

Yes No Unsure

What is the primary language spoken in the home? (Our waitlist for boys who require a Spanish Speaking Mentor is currently at capacity.) *

English Spanish

The Sports Buddies Program requires transportation to the events, which would be 1-2 times a month on Saturdays. This program is typically not a good fit for families that rely on public transportation. If you are familiar with the family's transportation situation please indicate below: *

The family has a car The family has access to a car The family uses public transportation I am not familiar with the family's transportation situation

What is your primary reason for you wanting this child to have a Big Brother / Big Sister? *

Comments or Additional Information

If you are submitting this referral form, but you are not the child's parent/guardian, the following information is required. Please note if you have not spoken to the family about the program and received permission to make this referral we are unable to move forward until we have confirmation from you that permission has been given. Thank you!

Referral Source Name

First Name Last Name

How do you know or work with this child?

E-mail

Phone Number

- Area Code Phone Number

If you are a professional that works with this child (teacher, social worker, counselor, other), what organization/school/agency do you represent?

Please tell us which of these are true:

I have spoken with the child's parent /guardian about this referral. Please contact the family directly. I have not spoken with the parent/guardian about this referral. Please contact me directly to discuss this referral.

Youth Referral Form