Refer a Child.

Use the form below to refer a child you know for mentorship.

"*" indicates required fields

Child’s Name

First Last

Reason for Referral

Child’s Date of Birth

Month

Day

Year

Child’s Gender

Male

Female

Child’s Ethnicity

School Child Is Attending

Who is involved in this child’s life?

Biological Mother

Biological Father

Neither

Parent In Prison or On Parole

Parent in prison or on parole

Neither parent in prison or on parole

I don’t know

Guardian’s Name

First Name Last Name

Guardian’s Address

Street Address Address Line 2 City State Zip

Guardian’s Phone

Guardian’s Email

Your Name

Referring Agency

Referrer’s Phone

Referrer’s Email

Program Requirements*

Please confirm each.

The child I am referring wants to have a mentor and is aged between 5 and 14.

The parent/guardian of the child I am referring wants mentoring for their child.

I understand that this child must be in the Wichita area for at least the next year in order to be matched.

I, and the parent/guardian of the child I am referring, understand that Youth Horizons is a non-denominational Christian organization.

This field is for validation purposes and should be left unchanged.