The Cassie Lucille Foundation Youth Mentee Intake Form

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Please fill out this form completely for your child's emergency contact information

Email *

Child's Name (First & Last) *

Child's Birthdate *

YYYY

Child's Gender Identity (Optional) *

Male

Female

Non-binary

Prefer not to answer

Other:

Your child's t-shirt size (for field trip/event purposes) Adult Sizes *

XXL

Other:

Parent/Guardian Name (If under 18) *

Parent's Phone Number (with area code) *

Home Address *

Does your child have any health conditions, special needs, or requirements that your mentor should be aware of? (e.g., physical limitations, medical conditions, etc.) If YES, list below or if NO type N/A *

Do you have any dietary restrictions or allergies? (Food, Environment, Medication) part 1 *

Yes

Dietary Restrictions or Allergies (part 2). If you answered YES to the above question, please list all allergies below. If NO, type N/A *

Does your child require emergency medication? (Epi-Pen, Benadryl, Asthma Inhaler, ect.) part 1 *

Yes

Emergency Medication (part2). If you answered YES to the above question, please list all allergies below. If NO, type N/A *

What areas will your child need support or help? *

Social/Emotional

Academic

Other:

Required

What challenges or obstacles is your child currently facing that you would like support with? (School, family, self-confidence, etc.) *

What qualities or traits would you like your mentor to have? (E.g., patient, good listener, energetic, etc.) *

How often would you like to meet with your mentor? *

Once a week

Bi-Weekly

Once a month

Do you prefer meeting in-person, virtually, or a mix of both? *

In Person

Virtually

Mix of Both

No Preference

Is there anything else we should know about your child to help ensure a safe and supportive mentoring experience? *

Consent & Acknowledgment:

I understand that the Cassie Lucille Foundation will use this information solely to match my child with a mentor and to provide support. I and my child agrees to be respectful and responsible during my participation in this program.

Yes, I understand & Acknowledge

Required

I understand that my mentor’s role is to provide guidance, encouragement, and support, and that the mentor is not a counselor or therapist. *

Yes, I understand

Required

Parental/Guardian Consent (If Under 18) *

I consent to my child’s participation in The Cassie Lucille Foundation’s mentoring program, and all information is kept confidential and used solely for the purpose of mentoring.

Required

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