This application is for referral of students at GODFREY-LEE EARLY CHILDHOOD CENTER only.
If the person completing this form is someone other than the student's parent/guardian, a Student Information Release Form (Mentor Request Form) must be completed by the parent/guardian prior to referring the student. [These forms are available in the Mentor Center or by e-mailing
Name of individual making referral:
Relationship to the student:
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This form was created inside of Affinity Mentoring.