• 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.
  • PARENT/GUARDIAN INFORMATION

  • Background of 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.
  • Does this child identify as:
  • FAMILY AND SCHOOL INFORMATION

  • Please describe allergies, medical or physical concerns for the child that agency staff and the mentor should know about.
  • 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 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.
  • Please check all that apply.
  • Please check any/all that apply to this child.
  • Please check any/all that apply to this child.
  • MM slash DD slash YYYY