Youth Application for a Mentor /Tutor



TUTOR/MENTOR PROGRAM
YOUTH APPLICATION

Please Note: Profile information is crucial to the effectiveness of our program and must be filled out completely with attached permission forms signed and submitted before child will be considered for tutor/mentor placement.

Name of Caregiver: Home Phone:
Address of Foster Home: Cell Phone:
Email Address: Fax No.:
Child's Full Name: Date of Birth:
Name of School: District:
Name of Teacher: Teacher/Schools Phone No.:
Is there a current IEP w/an Arizona School District? If so, where is the IEP?
Race/Ethnicity:    
DCS Case Manager's Information:
Name:
Phone:
Email:
Alt. Phone:
Reason for placement in State Custody:
Length of time in State Custody
How long do you anticipate child will remain in state custody?
Can child make a one year commitment to our program? Yes No
Does child understand the concept of Tutor/Mentor and is he/she willing to participate? Yes No
   
Please identify and explain any of the following barriers that may apply to this child:
   
Academic History (Challenges)
Diagnosed Learning Disability?
Diagnosed Psychological Disorder:
   
Is the applicant currently seeing a counselor or therapist? If yes, please give Therapist’s Name and phone number: Yes No
Any prescription medication, if yes, please list types of medications and dosages: Yes No
Health Issues? Please explain: Yes No
Behavioral Issues? Please explain: Yes No
Has either of his/her parents ever been incarcerated? Please explain: Yes No
Does the child have any Misdemeanor or Felony Convictions? Please explain: Yes No
Is the Child on probation? Yes No
What skills or everyday situations does this child need assistance with?
Please give a brief description of child’s interests, general demeanor and attitude:

Portal login to verify grade:
Website Url:
User Name:
Password:

Signature of Caregiver: Date: