"*" indicates required fields

About the Child

This form can be completed by the child's teacher, principal, counsellor, youth worker, etc., or their parent/guardian. To be eligible for a mentor, the child must enrolled at an elementary school in Greater Victoria (Sooke to Sidney), the Comox Valley or on Salt Spring Island.   Submitting an application form does not guarantee acceptance into our programs or that a mentor can be found for this child. The Informed Consent and COVID-19 Waiver Forms must be signed by the child's parent/guardian before the child can be matched with a mentor.
Child's Name:*

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:*
Address:

More About the Child

This section is used for statistical purposes only. You do not need to complete this section if you are uncomfortable providing answers. Your answers will not affect the child's application to the program.
Child's Date of Birth:*
Does this child identify as:
Please describe allergies, medical or physical concerns for the child that agency staff and the mentor should know about.

SCHOOL INFORMATION

Location of In-School Mentoring Program*
Where is the child's school located?

Activities List - Fun Things to Do Together

Please select the activities, events and/or places the child enjoys or would like to try with their mentor:
Please select all that apply:
Please check the characteristics that describe the child:*
Please note: While we do not match girls with male-identifying mentors as we always have more boys on our wait-list, we do match boys with female-identifying mentors.
(i.e. sporty, creative, patient, outgoing, calm, etc.)
(e.g. self-esteem, cooperation, emotional-regulation, etc.)

ABOUT the CHILD'S EXPERIENCES

You do not have to complete this section if you are not comfortable sharing information about the child or family with us. However, we strive to match each child with the best available mentor and knowing more about the child’s experiences helps us determine who might be the best match for them.
Child is experiencing/or has experienced:
Please check all that apply.
Child is experiencing/or has experienced:
Please check any/all that apply to this child.
At school, child is experiencing/or has experienced:
Please check any/all that apply to this child.
Name of Person who Completed Form:
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.