Canadian Citizen Youth Referral Application
Please do your best to provide the most accurate and up-to-date information as possible.

WHO SHOULD COMPLETE THIS FORM?
Only a worker from an organization currently involved with the Canadian youth (e.g. health practitioner, teacher, counselor, social worker, etc.) can complete this form.

CANADIAN CITIZEN YOUTH CRITERIA:
– Born in Canada
– Ages 6 -15

THE MATCHING PROCESS:
The match with a volunteer is based gender, common interests, compatibility and location / proximity to one another. Youth Assisting Youth strives to promote diversity. We ask for your cooperation in adhering to our Access & Equity Policy (which can be obtained upon request).
Email address *
I have read Google's Privacy & Terms policy (https://www.google.com/policies/), and understand that all the information I provide is confidential, subject to this policy *
Required
I am aware that this is the application for making a referral of a "Canadian Citizen Youth." *
Required
Today's date *
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YYYY
How did you first hear about Youth Assisting? *
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