Amplified Mentoring Program Youth Referral Form
The Amplified Mentoring Program provides one-to-one mentoring for youth ages 12-17. Youth meet with an adult volunteer mentor for 6 to 8 hours per month for a minimum of 9 months.

Mentoring Can Support a Young Person Who Is:
- Able to express why they want a mentor
- Looking for community connection and positive adult support
- Willing to work one-on-one with a volunteer mentor
- Struggling in school or lacking interest in school
- Experiencing a major life transition
- Or has a history of personal or family substance abuse

Not everyone is a good fit for mentoring. Youth who are unwilling to follow program rules, exhibit aggressive and/or violent behavior, are at risk for harming themeselves or others, currently addicted to hard substances or are experiencing severe mental illness are not appropriate referrals.

Youth Information
Youth's Name *
Your answer
Gender *
Age *
Your answer
Parent/Guardian Name(s) *
Your answer
Relationship to Youth *
Your answer
Phone Number *
Your answer
Email *
Your answer
School *
Your answer
City *
Your answer
Grade *
Your answer
Referrer Information
Name of Person Making the Referral *
Your answer
Referral Date *
MM
/
DD
/
YYYY
Agency/Program/Relationship to Youth *
Your answer
Phone Number *
Your answer
Email *
Your answer
The parent/guardian is aware that I made this referral for their child *
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