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Refer A Child For Mentoring

Youth Horizons / Refer A Child For Mentoring

Mentoring Referral Form

Complete the form below to refer a child for Youth Horizons mentoring.

Child’s Gender:MaleFemale

Child’s Date of Birth:
Child’s Ethnicity:

Who is involved in the child’s life:
Biological MotherBiological FatherNeither

Does the child have a parent in prison or on parole?
YesNoUnsure


Please confirm and check off program requirements:
The child I am referring wants to have a mentor and is between the ages of 5 - 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
I understand that this child must come from a single parent home to be eligible