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Child’s Gender:MaleFemale
Child’s Date of Birth:
Child’s Ethnicity: —Please choose an option—CaucasianAfrican-AmericanHispanicAmerican IndianOther
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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