Active Achievers Youth H.E.L.P

First Name:(Required)

Last Name:(Required)

Gender:(Required)

Male

Female

Date of Birth:(Required)

Month

Day

Year

Age:(Required)

Address:(Required)

City:(Required)

Postal Code:(Required)

Cell Phone Number:(Required)

Home Phone Number:(Required)

Email Address:(Required)

Is The Youth Currently Attending School?(Required)

Yes

Current School:

Grade:

Languages Spoken:

Families Cultural Background:

Do You Need An Interpreter?(Required)

Yes

Which Best Applies To The Youth?(Required)

Citizen

Permanent Resident

Refugee

Other

Specify If Other:

Does The Youth Identify As A Newcomer?(Required)

Yes

Is The Youth On Any Medication That We Need To Be Aware Of?(Required)

Yes

If Yes, Describe:

Any Allergies?(Required)

Yes

If Yes, Describe:

Does The Youth Have Any Emotional, Mental, Physical, Or Specific Medical Health Conditions That We Should Know About?(Required)

Yes

If Yes, Describe:

Is The Youth In Counseling Or Receiving Services From Child Protective Services?(Required)

Yes

If Yes, Describe:

Is The Youth Or Family Currently Involved With Child Protective Services?(Required)

Yes

What Is The Level Of Involvement?

Family Enhancement

Protection

Office Location:

Phone Number:

Social Worker’s Name:

Emergency Contact Information

Contact Name:

Relationship:

Phone No.1:

Phone No.2:

Parent/Guardian Information Where Applicable And Youth Ages 12 - 17 Years Old

Parent/Guardian's First And Last Name:

Relationship:

Phone Number:

Email Address:

Languages Spoken:

Do You Need An Interpreter?

Yes

Other Parent/Guardian(S) Name(S) If Any:

(Enter N/A if not applicable)

Relationship:

Phone Number:

Getting To Know The Youth This Will Help Us With Matching The Youth With A Compatible Mentor

Why Does The Youth Need/Want A Mentor?(Required)

Tell Us About The Youth’s Personality And Strengths(Required)

What Would You Say Are Some Of The Youth's Challenges?(Required)

Is There Anything You Would Like Us To Be Aware Of That Would Assist Us In Finding The Right Mentor For The Youth?(Required)

Yes

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, Leadership Skills, Or Other Skills:(Required)

How Did You Hear About This Program? Select All That Applies:(Required)

The Academy Builders

Social Media

The Academy Builders Email Newsletter

Word Of Mouth

Other

Specify If Other:

By Ticking On The Checkbox Bellow, You Consent To Receive Services From The Academy Builders

I Agree To The Terms Mentioned Above

Complete Name:

Referral To Be Completed By The Referring Agency Only

Referring Agency:

Referred By:

(Name of Referrer)

Phone Number:

Email Address:

Emergency Contact Information

Parent/Guardian Information Where Applicable And Youth Ages 12 - 17 Years Old

Getting To Know The Youth This Will Help Us With Matching The Youth With A Compatible Mentor

Referral To Be Completed By The Referring Agency Only

Have Questions?

Have Questions?