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Legacy Leaders Mentoring Sign up Information & Assesment Form

Please fill out this form as best you can so we can provide you with the most relevant service.

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Mentee Full Name *

First

Last

Email *

Phone Number *

Gender *

Male
Female
Other

Date of Birth *

Address *

Is the youth currently attending school? *

Yes
No

Current School *

Grade *

Language Spoken *

Is the youth on any medication we need to be aware of? *

Yes
No

If yes, please describe:

Does the youth have any emotional, mental, physical, or specific medical health conditions that we should know about? *

Yes
No

If yes, please describe:

Is the youth in counseling or receiving services from other agencies? *

Yes
No

If yes, please describe:

Social Worker's name *

Social Worker's phone number *

EMERGENCY CONTACT INFORMATION *

Relationship *

Phone # 1: *

Phone # 2 *

PARENT/GUARDIAN INFORMATION *

For youth 17 years of age or younger

Relationship to youth: *

Phone Number *

Email *

Other Parent/Guardian (s) Name (s) if any *

Contact Phone *

GETTING TO KNOW THEM *

This information will help us with matching the youth with a compatible mentor.

Tell us about the youth’s personality and strengths *

What would you say are some of the youth's challenges? *

Is there anything you would like us to be aware of that would assist us in finding the right mentor for the youth? *

Yes
No

If yes, please describe:

List some of the goals/changes the youth would like to achieve while in the program. This could either be academic, social, and personal skills, cultural connection, professional development, networking, communication skills, or leadership skills *

How did you hear about this program?

By signing this document, you consent to receive services from the Wendell Scott Foundation. *

INFORMATION # health

REFERRAL AGENCY

(TO BE COMPLETED BY REFERRING AGENCIES ONLY)

Referred by (name) *

Phone Number *

Email *

Service(s) requested Please choose one

Mentoring
Truancy Mentoring
Parent-Aide
Transportation
Camp Cultivation Summer Camp

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434-533-0097

info@wendellscott.org

PO Box 3734, Danville, Virginia 24543

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