Youth Application and Assessment

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

Street Address of Foster Home

City, State, and Zip Code of Foster Home

Email Address

Child's Full Name

Race/Ethnicity

Home Phone

Cell Phone

Fax No.

Date of Birth

Child's Gender

Child's Primary Language

Name of School

Name of Teacher

District

Teacher/Schools Phone No.

Is there a current IEP w/an Arizona School District?

No Yes

Case Manager Name

Case Manager Phone

Case Manager Alt. Phone

Case Manager Email

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?

No Yes

Does child understand the concept of Tutor/Mentor and is he/she willing to participate?

No Yes

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?

No Yes

Any prescription medication?

No Yes

Health Issues?

No Yes

Behavioral Issues?

No Yes

Has either of his/her parents ever been incarcerated?

No Yes

Does the child have any Misdemeanor or Felony Convictions?

No Yes

Please Explain

Is the Child on probation?

No Yes

What skills or everyday situations does this child need assistance with?

Please give a brief description of child’s interests, general demeanor and attitude

Signature of Caregiver

Date

I certify this is my electronic signature