Thank you for your interest in referring a youth to our Project Hero mentoring program. Please complete this form to the best of your ability and a program coordinator will reach out to the youth soon. If you have questions about the program or about the form, please contact program coordinator Carlos Ramirez - caramirez@educationcompact.org

Name of Youth *

First Name

Last Name

Date of Birth *

YYYY

Gender *

Female

Male

Race/Ethnicity *

Please select the one the youth most strongly identifies with

White/Caucasian

Latino/a/x

African American/Black

Asian

Pacific Islander

Native American

Other

Current Grade Level *

7th

8th

9th

10th

11th

12th

Post Secondary

High School Drop Out

Working on High School Equivalency

Other

Youth's Address *

Youth's Phone Number *

If youth does not have a phone, please indicate parents number.

(###)

###

####

Youth's Email

Parent Name *

Parent/Guardian Language Preference

English

Spanish

Other

Parent Phone Number

If youth is under 18

(###)

###

####

Are there any previous or existing court conditions/criminal offenses that we should be aware of? If so, please specify. *

Youth is being referred for support in the following (please only select top three areas): *

Academic Issues

Behavioral Issues

Study Habits

Social Problems

Criminal Activities

Family Concerns

Vocational Guidance

Gang Affiliation

Have the youth taken interest in any career area? If so, please specify.

What is the best way to communicate and build rapport with this youth? *

Is there any additional information that we should know about the youth? *

What are some of the youth's areas of strength? *

Has youth been informed of referral to the Project Hero program? *

Yes

Name and agency conducting referral *

Example: Jane Doe, School Counselor

If more information is needed, please provide the best contact information for person conducting referral *

We will receive your referral shortly and will initiate contact. If you have any questions about the referral or about the program contact our program coordinator:

Carlos Ramirez

caramirez@educationcompact.org

Thank you and have a great day!