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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