Code Switch: Mentee Interest/Referral Form
Thank you for your interest in Code Switch. Please use this form to refer girls to our mentorship programs. We will reach out to the family and student by phone and email once your referral is received. Youth can also refer themselves. Keep in mind, Code Switch youth must meet the following criteria:

Be 11-21 years of age
Speak and understand English
Live in Southern Nevada
Enrolled in a K-12 area middle or high school (not home-schooled)
Give written assent (agreement) to participate
Have written consent from a parent/legal guardian to participate ( required if under 18)
Self-Identify as a Girl/Young Woman of Color wanting mentorship and support through Code Switch programs
Be referred to the program by a parent, legal guardian or caregiver; appropriate school-based professional, or affiliates with a Code Switch community-based partner

Email address *
First and Last Name of Individual Making the Referral: *
Role & Organization: *
Relationship to Referent: *
Best Contact Phone Number (required): *
Type of Referral: *
Reason for a Referral (check all that apply) *
Required
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