In-School Mentoring Referral Form About the ChildThis 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:* First Last PARENT/GUARDIAN INFORMATIONParent/Guardian Name:* First Last Address: Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone:*Email: More About the ChildThis 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:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Gender:*MaleFemaleNon-BinaryTransgenderOtherCultural Background:Does this child identify as:I don't know/prefer not to sayEnglish CanadianFrench CanadianFirst Nation/Metis/InuitPacific IslanderMiddle EasternIndo-ChineseCentral/South AmericanAfricanSouth East AsianAmericanAsianEuropeanStatus in CanadaI don't know/prefer not to sayBorn in CanadaNew Immigrant (arriving within the last 5 years)RefugeeMedical Information for child:Please describe allergies, medical or physical concerns for the child that agency staff and the mentor should know about.Family Type:Single Parent - FemaleSingle Parent - MaleTwo Parent - BiologicalTwo Parent - BlendedAdoptive FamilyFoster Family/Child in CareRaised by Grandparent(s)Raised by other(s)I don't know/prefer not to sayCustody Arrangement:SoleJointIn Care - PermanentIn Care - TemporaryOtherI don't know/prefer not to saySCHOOL INFORMATIONLocation of In-School Mentoring Program*Where is the child's school located? Comox Valley Victoria or Saanich Central Saanich or North Saanich Salt Spring Island Sooke or Langford Name of Child's School:* Name of Child's Teacher: Child's Grade:*Kindergarten123456789101112Not in schoolActivities List - Fun Things to Do TogetherPlease select the activities, events and/or places the child enjoys or would like to try with their mentor:Please select all that apply: Animals Cooking/Baking Educational Activities Music Talking Arts & Crafts Computers Outdoor Activities Building (Lego) Cultural Activities Indoor Activities Reading / Books Board Games / Card Games Dance Sports What other activities would they like to try with their mentor? Please check the characteristics that describe the child:* Highly Active Friendly Outgoing Helpful Quiet Shy Withdrawn Other Please explain why this child could benefit from having a mentor:*Please describe this child's strengths:What class/classes should this child not miss? How important is it that the child be matched with a mentor of the same gender?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.Match with the first available mentorMatch only with a mentor of the same genderWhat personality traits do you think the mentor should have?(i.e. sporty, creative, patient, outgoing, calm, etc.) Please list areas that a mentor could help the child develop:(e.g. self-esteem, cooperation, emotional-regulation, etc.)Is there anything we should be aware of that would assist us in finding the right mentor for this child?ABOUT the CHILD'S EXPERIENCESYou 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. Social isolation at home, school or in the neighbourhood Parental separation or divorce MCFD or child welfare services being involved in the home A household member with a substance abuse problem A household member with a mental health illness A household member who has been incarcerated or involved with the police Being bullied or bullying others Violence (often seen or heard) at home, school or in the neighbourhood The death or terminal illness of someone close to them Arriving in Canada with refugee status or arriving in Canada within the last 5 years Financial stress in the household Insecure employment in the household Mental health illness Child is experiencing/or has experienced:Please check any/all that apply to this child. Peer difficulties Low self-esteem/confidence Difficulty relating to adults Difficulty relating to peers Low communication skills Emotional coping difficulties Limited access to activities Being withdrawn Lack of adult supports An eating disorder Emotional, physical or sexual abuse Self-harm Suicidal ideation/attempt Criminal/gang involvement Siblings with high needs Personal hygiene issues Living on reserve Chronic illness of a family member At school, child is experiencing/or has experienced:Please check any/all that apply to this child. Attention difficulties ADHD/ADD (suspected/confirmed) Taking behaviour medication Difficulty with authority Not engaged in school Poor attendance Lack of class participation Struggling academically Learning disabilities Disruptive behaviour in school Difficulties staying focused Lack of motivation Difficulty interacting with adults English as a second language Child attends learning program Name of Person who Completed Form: First Last Date Form was Completed: MM slash DD slash YYYY
