The Legacy Project - Mentee Application
Application to be completed by child's guardian.

Information about your child will be collected and shared between Springfield City Youth Mission and Save Our Youth for program evaluation and improvement. No personal details that identify your child will be shared outside of these organizations.
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Email *
Child's Name *
Gender *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Street Address  *
City *
Zip Code *
School Attending *
Grade *
School District *
Parent/Guardian Name(s) *
Preferred Email *
Parent/Guardian Phone *
Emergency Contact Name (Who should we contact if we can't get a hold of you?) *
Emergency Contact's Phone Number *
Emergency Contact's Relationship to Student *
Emergency Contact's Email *
Household Status: *
Language(s) Spoken in Home:  *
Required
Ethnic Origin: *
Annual Family Income: *
Services your family receives:  *
Required
Please select any that apply to your family or a member in your family:  *
Required
Please list ALL others living at the same address (Please include: name, DOB, gender, and relationship to child named above):  *
Why are you referring your youth for a mentor and what are some relevant things that have happened? *
Child’s Email:  *
Child’s Phone (if applicable): *
TO BE COMPLETED WITH YOUR CHILD:
Please complete the remainder of this application with your child.
Please ask your youth to answer in his/her own words this question: "Why would you like a mentor?" *
Please select any of the following challenges the child has experienced. (Check all that apply.) *
Required
Additional comments about challenges (Optional) *
Please select any of the child’s skills and interests from the list below (Check all that apply.) *
Required
Additional comments about skills and interests (Optional) *
By signing below, I agree to the following: *
Required

I understand that my signature on this form allows Springfield City Youth Mission (SCYM) to use my child’s data for the purpose of evaluating programs and improving the SCYM’s ability to meet my child’s needs.

I understand that my records are protected and that any information released pursuant to this consent remains subject to restrictions in applicable federal and state laws. 

I understand that my child’s participation in this program cannot be conditioned in any way upon my executing this Authorization.    

 *
Parent/Guardian Signature *
Youth Signature *
Please provide the name, phone number, and email address of an adult outside of the family (a teacher, a pastor, a counselor, etc.) who knows you well and can serve as a referral for your participation in the program. Please share your relationship with this person. *
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