Mentorship Referral Form

Mentorship Form

Youth's Name *

First and Last Name

Date of Birth *

Month, Date, Year

Age *

Address *

please include if you live in North Battleford, Battleford or a surrounding community.

Youth Contact Information - Phone Number/Email *

Gender Identity *

Male

Female

TransgenderTransgender

Non-binary/non-conforming

Prefer not to respond

Ethnicity *

Indigenous

Metis

Asian

Black/African

Hispanic/Latinx

Caucasian

Other

Prefer not to respond

School *

ElementaryElementary

Sakewew High School

John Paul II Collegiate

North Battleford Comprehensive High School

Not currently enrolled

Current grade / if not in school what was the last grade completed *

Allergies / Medications *

Guardian Name, Relationship and Contact Information (Phone Number/Email) *

Referred By *

Phone *

Email *

Reason(s) for Referral *

More Details (please describe the goals youth wants to work on) *

Involvement with Community Organizations (ex: BGC, Bridges 4 Children, Counsellor, Psychiatrist, Psychologist, organized sports/activities) *

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