Youth Application : Enroll Your Child : Reach Our Youth

Contact Information

Child's Name (first and last) (Required)

Date of Birth (Required)

Age (Required)

Gender (Required)

Race

Address (Required)

City (Required)

State

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Zip

Phone (Required)

Email (Required)

Who Does the Child Live With? (Required)

Please check all interests your child has:

Please list any other interests your child might have (Required)

Extra-Curricular activities youth is currently involved in

Physical problems/allergies/disabilities (physical or learning)

Reason for Referral (Required)

What would you like to see youth gain from participation in ROY? (Required)

Youth currently or in the past on probation? If so, please explain: (Required)

How did you learn about ROY? (Required)

How does the youth get along with other children? (Required)

How does the youth relate to adults (parents, teachers, neighbors)? (Required)

School Attending (Required)

Grade (Required)

Estimated Graduation Year?

Has the child/teen ever been held back in school? If so, what year?

What is his/her attitude towards school? (Required)

What is their favorite subject & why?

What is their least favorite subject & why?

List any address you’ve held in the past 10 years:

Please list any additional information on youth and family history that will help ROY to understand the child’s needs. This helps us to better serve the youth and make an appropriate match-up with a volunteer mentor. (Required)

I hereby give permission for my child to participate on a voluntarily basis in Reach Our Youth (ROY). I agree to release ROY and the volunteer mentors from any liability concerning my child.

Parent’s or guardian’s signature

Date

What kind of mentor do you see your child being matched with? (i.e. gender, age, interests) (Required)