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? (Required.)

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2. Please provide the full name of the child you are referring below: (Required.)

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3. What school does the child attend? (Required.)

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4. What grade is the child in? (Required.)

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

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6. Which mentoring program do you feel would be best for this child? (Required.)

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

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

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

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: (Required.)

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.) (Required.)

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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. (Required.)

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

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11. Please provide your email address and phone number: (Required.)

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12. As the person referring this child to the mentoring program I understand: (Required.)

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? (Required.)

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: (Required.)

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:

Ann Willison
New Opportunities, Inc.
23751 US-30, Carroll, IA 51401
1710 W Main St, Sac City, IA 50583
Sac Phone: 712-662-3236 ext. 7041
Carroll Phone: 712-792-9266 ext. 1021
Email: awillison@newopp.org
Fax: 712-792-1457

Question Title

* 1. What is today's date? (Required.)

Question Title

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

Question Title

* 3. What school does the child attend? (Required.)

Question Title

* 4. What grade is the child in? (Required.)

Question Title

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

Question Title

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

Question Title

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

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.) (Required.)

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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. (Required.)

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

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

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

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* 13. How should the application be sent? (Required.)

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* 14. I am interested in becoming a mentor: (Required.)

1. What is today's date? (Required.)

2. Please provide the full name of the child you are referring below: (Required.)

3. What school does the child attend? (Required.)

4. What grade is the child in? (Required.)

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

6. Which mentoring program do you feel would be best for this child? (Required.)

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

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

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. (Required.)

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

11. Please provide your email address and phone number: (Required.)

12. As the person referring this child to the mentoring program I understand: (Required.)

13. How should the application be sent? (Required.)

14. I am interested in becoming a mentor: (Required.)