Mentoring Referral Form

New Opportunities Mentoring Program

This referral is to be completed for youth (5-17) for our community-based mentoring programs that serve Audubon, Carroll, Greene, Guthrie, and Sac Counties.

Are you a parent or guardian of the youth being referred? You can complete our online application here today!
*Person filling out the youth's application MUST be their parent or acting guardian.

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* 1. What is today's date?

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* 2. Please provide the full name of the child you are referring below:

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* 3. What school does the child attend?

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* 4. What grade is the child in?

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* 5. What is the child's teacher's name & email (if known)?

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* 6. Which mentoring program do you feel would be best for this child?

Community Based Mentoring-child would meet with an adult (18+) mentor at their home, on the weekends, and during the summer.

School Based Mentoring-child would meet with a high school mentor or adult mentor for 30 minutes once per week during the school day. (Carroll)

After School Program-child would meet with an adult or high school mentor after-school for homework assistance. (East Sac)

I think this child would benefit from any of the programs.

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* 7. The child being referred needs one on one assistance in the following areas. Check all that apply:

Academics

Behavior

Social Skills

Study Skills

Self Esteem

Family Issues

Relationship with Peers

Please explain any checked areas.

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* 8. Do you have any specific suggestions regarding the type of Mentor to be matched with this child? (age, gender, special training, etc.)

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* 9. Please provide the child's parent/guardian's address, phone number, and email address.
Once this form is reviewed I may contact him/her to set up an appointment to get the child enrolled in the program.

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* 10. Please type your full name and relationship to the child you are referring:

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* 11. Please provide your email address and phone number:

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* 12. As the person referring this child to the mentoring program I understand:

Mentors are volunteers and are asked to mentor once per week (up to 4 hours per month).

If requesting a high school mentor, I understand schedules change at semester and if the time the mentor is available doesn't work with the child's teacher's schedule the child may not be assigned a mentor that school year or not be mentoring the entire school year.

If a problem arises between the mentor and the child, there is a lack of consistent mentoring, or any other issue with the match, contacting the Mentoring Coordinator immediately is very important.

Please understand your cooperation is needed in making our program a success. Our program coordinator is standing by to address your concerns year-round.

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* 13. How should the application be sent?

Apply online (See link below for the application)

Have the application be sent via Email

Have the application be sent via USPS/Mailed paper-copy

Other (please specify)

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* 14. I am interested in becoming a mentor:

Yes

Are you a parent or guardian of the youth being referred? You can complete our online application here today!
*Person filling out the youth's application MUSTbe their parent or acting guardian.

For any further questions, concerns, or additional information contact our Mentoring Program Coordinator today:

Andrea Ross-Mueggenberg
New Opportunities, Inc.
1710 West Main St.
Sac City, IA 50583
Sac Phone: 712-662-3236 ext. 7041
Carroll Phone: 712-792-9266 ext. 1021
Email: aross@newopp.org
Fax: 712-662-3593

Question Title

* 1. What is today's date?

Question Title

* 2. Please provide the full name of the child you are referring below:

Question Title

* 3. What school does the child attend?

Question Title

* 4. What grade is the child in?

Question Title

* 5. What is the child's teacher's name & email (if known)?

Question Title

* 6. Which mentoring program do you feel would be best for this child?

Question Title

* 7. The child being referred needs one on one assistance in the following areas. Check all that apply:

Question Title

* 8. Do you have any specific suggestions regarding the type of Mentor to be matched with this child? (age, gender, special training, etc.)

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* 9. Please provide the child's parent/guardian's address, phone number, and email address. Once this form is reviewed I may contact him/her to set up an appointment to get the child enrolled in the program.

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* 10. Please type your full name and relationship to the child you are referring:

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* 11. Please provide your email address and phone number:

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* 12. As the person referring this child to the mentoring program I understand:

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* 13. How should the application be sent?

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* 14. I am interested in becoming a mentor:

* 9. Please provide the child's parent/guardian's address, phone number, and email address.
Once this form is reviewed I may contact him/her to set up an appointment to get the child enrolled in the program.