Clinton Schools Youth Mentoring Choices/Campus Pals/Lunch Buddies Student Application
Dear Parent/Guardian,

A child's teacher or counselor is often aware of his/her needs and struggles. It is the opinion of your child's teacher and/counselor that a mentoring relationship will assist your child in becoming an individual with high self-esteem and strong decision-making skills that will result in more successful performance in and outside of school. A child's teacher, counselor, may contact you, the parent/guardian, to get your child enrolled in Clinton Youth Mentoring Program for the above reason.
Below is a description of the different programs offered by Mentor Clinton County in the Clinton Community School District. Community members come in and become mentors to your children within each of these programs. Mentors are screened and background checks completed.

Bluff Elementary School Choices - Choices is a supportive after-school group mentoring program designed to empower 4th and 5th grade students to become successful students, responsible citizens and peers with healthy self-esteem. Activities offered will help your son/daughter learn skills that result in a more successful performance in school and outside of school. The activities include discussions, projects, role-plays, homework assistance and fun engaging activities. Students in this program will need to be picked up by a parent.guardian, as busing is not provided after the program. The program will meet every Thursday from 3:00pm-5:00pm at Bluff Elementary School.

Clinton Middle School Choices - Choices is a supportive after-school group mentoring program designed to empower middle school students to become successful students, responsible citizens and peers with healthy self-esteem. Activities offered will help your son/daughter learn skills that will result in a more successful performance in school and outside of school. The activities include discussions, projects, role-plays, homework assistance and fun engaging activities. No busing home will be provided after the program; your son/daughter may ride the city bus, parents can pick up, or your child can walk home. The program will meet every Wednesday from 1:45pm to 3:15pm at Clinton Middle School.

Clinton Middle School Campus Pals - Campus Pals is a group mentoring program at Clinton Community College. Campus Pals is a supportive program designed to empower middle school students to become successful students, responsible citizens and peers with healthy self-esteem. The activities offered with the program include discussions, projects, role-plays, homework assistance and fun and engaging activities. Busing is provided to Clinton Community College, but busing is not provided after the program. Parents will need to pick their child up at CCC, have their child ride the city bus or walk home. The program will meet every Monday from 3:45pm to 5:00pm.

Lunch Buddies at Jefferson & Bluff Elementary School - Lunch Buddies is a youth mentoring program for 4th and 5th grade students at Jefferson & Bluff Elementary. Lunch Buddies is held during your son/daughters lunch hour once a week. A mentor from the community will eat lunch with your son/daughter and help them develop logical thinking and decision-making skills, responsible behavior and healthy relationships with their peers, teachers, and other adults thru the conversations they have.

We ask that students in the program make it their best effort to attend the weekly mentoring sessions. By attending the weekly mentoring sessions, students will be able to become successful students, responsible citizens and peers with healthy self-esteem. They will be able to build a relationship with other peers and adults, along with gain another positive role model in their lives. Different subjects will be talked about within the mentoring program (how to build self-esteem, ways to avoid violence, information about cliques, how to say no to drugs, tobacco education, and goal setting), and by attending weekly sessions, students will have an understanding on these subjects and the skills needed to avoid certain behaviors. Different community members will be coming into the program and giving presentations or doing activities with your children. Each week will have a fun activity that will keep your child wanting to come back!

Campus Pals and Choices will host quarterly events for mentors and mentees. Lunch buddies will be invited to different events as well. The purpose of these events is to show students alternative safe community events and resources. Parents will be informed of the events ahead of time.

Quarterly newsletters will be sent out to families that will include dates of upcoming sessions, what your child will be learning at each session, how to build on those lessons at home, upcoming events in the community and different substance abuse facts. We encourage conversations to occur at home!

If you have any questions about the above programs, please contact me at 563-243-4223 or by emailing me at program2@bbbsclinton.org. I look forward to working with your child this year!
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Child's Full Name *
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Child's Date of Birth *
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Parent/Guardian Name & Relationship to Child *
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Home Phone Number *
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Parent Cell-Phone Number *
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Home Address *
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City *
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State *
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Zip Code *
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Parent/Guardian Email Address *
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Program Signing Child Up For
Child's Grade *
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Child's Teacher (or Homeroom Teacher) *
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Child's Race/Ethnicity *
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Parent Place of Employment *
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Parent Work Phone Number *
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May we contact you at the work number listed above? *
Please check the best number and time to contact you (the parent/guardian) *
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If we are unable to reach the parent/guardian, who is someone we could call who always knows how to reach you? Include name and phone number of this person. *
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What is the primary reason for you wanting your child to have a mentor? *
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Does your child know that you are applying for the program/they have been referred to the program? Does your child want to participate? *
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Do you anticipate any significant life changes over the next year, or have you had any in the past year, such as moving? *
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Will your child meet the requirements for the after-school programming of meeting once a week? *
Does your child have any medical conditions that we should be aware of? *
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Number of people (adults and children) in household
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Is the parent/guardian receiving income assistance at this time?
Is parent/guardian receiving assistance with housing? (Section 8, residence in public-housing, etc)?
Is child eligible for free or reduced lunch?
Does your child have a parent/guardian/caregiver with current or past military experience
If yes to above question, which branch and component:
Is the parent currently deployed? If yes, what are the dates of deployment?
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Is the parent retired from the military?
Is the parent separated/discharged (other than retired) from the military?
Does your child have a parent/caregiver who is considered fallen, wounded, or disabled by the military?
Does your child have a parent/guardian who is currently incarcerated? If yes, please explain
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Has your child ever been arrested or involved in the juvenile justice system? If yes, please explain.
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Within the last year, has your child been in trouble at school for:
My child needs help in the follow areas: *
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Please use this space for further descriptions/answers to the above questions, if needed.
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I give my son/daughter permission to participate in the Youth Mentoring Program hosted by Mentor Clinton County. I also understand that at no time will the volunteer be allowed to transport my child. I understand that my child will be asked to participate in pre/post program evaluation for statistical purposes. Please type your name and date below. *
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I give permission for my child to attend any field trips (quarterly events) with the Youth Mentoring Program. I understand that I will be notified in advance of the location of each field trip. Clinton Schools will provide transportation for these events. Please type your name and date below. *
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Additional paperwork to be signed/filled out by the parent/guardian will be mailed home upon completion of this application. Please return this paperwork ASAP.
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