Thank you for your request for a mentor! We’re excited to connect with you soon. Once you complete this form, our team will follow up to share more details about the program, the application process, and next steps.

To Be Requested by Guardian

Pearl Promise collects information about your child’s identity and requests your child’s participation in surveys to enhance our services and evaluate our program. This information is securely stored and used solely within the organization.

Date picker

How did you Hear about Pearl Promise's Kids Mentoring Program?

Child / youth first name

Child / youth last name

Gender

Male

Female

Other

Wednesday Night Mentees must be 8+

Community-Based Age must be between 10 - 17

Date of Birth

Month

Day

Year

Child / Youth Cell Phone (if applicable)

Multi-line address

Country/Region

Address

City

Zip / Postal code

School

Grade

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Parent / Guardian Name(s)

Relationship to Child

Phone

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Emergency Contact (different from parent, if applicable)

Phone

Relationship to Child

________________________________________

We collect this information below in order to receive grant funding as a nonprofit. We do not share outside the organization.

Please list ALL others living at the same address. (Include name, date of birth, gender, & relationship to applicant)

Has this youth been diagnosed with Autism, ADHD or other Neurodiversity?

Yes

So we can best support them, does the youth identify as LGBTQ?

Yes

Clearly explain why you are referring this youth for a mentor and relevant things that have happened.

To be completed by guardian & child/youth

Please ask your child: "Why would you like a mentor?"

Additional Comments

Additional Comments (Specify which video games, sports, clubs, etc.)

Final Agreement (Click Submit Below)

By signing below, I agree to the following:

Youth: To meet my mentor on a weekly basis for a minimum of one year.
Parent and Youth: To return my mentor's calls.
To allow Pearl Promise to contact an adult (teacher, counselor, pastor, etc.) outside the family who knows my child well if necessary

I understand that my signature on this form allows the Organization to use my child’s data for the purpose of evaluating programs and improving the Organization’s ability to meet my child’s needs.

I understand that my records are protected and that any information released pursuant to this consent remains subject to restrictions in applicable federal and state laws.

I understand that my child’s participation in this program cannot be conditioned in any way upon my executing this Authorization.

Parent Signature

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Child/Youth Signature

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