Participant Application Youth's Name(Required) First Middle Last Parent/Guardian Name(Required) First Last Relationship to Youth(Required) Mother Father Grandmother Other Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Check frequently?(Required) Yes No Home Phone(Required)Cell Phone(Required)Child's Birthdate Age(Required)Gender(Required) Male Female Race(Required) White American Indian Hispanic Other Does parent/guardian work?(Required) Yes No Days/Hours(Required)Employer(Required)Can parent be called at work?(Required) Yes No Best Time(Required)Work Phone(Required)Child's School(Required)Grade(Required)Teacher(Required)Family Status(Required) Single Married Divorced Separated Cohabiting Widowed Spouse's or Significant Other's Name(Required) First Last Non-Custodial Parent's Name First Last Has either parent been incarcerated?(Required) Yes No Please list all members of your household:(Required)NameSexAgeRelationship to Applicant Add RemoveParent/Guardian's Level of Education(Required) High School Technical College College Are you affiliated with a church?(Required) Yes No Name of Church(Required)How would you describe your child's personality and temperament?(Required)Select any of the following words you feel apply to your child:(Required) Cooperative Energetic Shy Outgoing Follower Nervous Quiet Talkative Friendly Confident Leader Aggressive Athletic Why do you/your child want to participate in a mentoring program(Required)Briefly describe your expectations for the Kinship mentoring program:(Required)Is your child available to meet with a mentor at least six hours per month and have contact at least once a week for a minimum of one year? Please explain any particular scheduling issues:(Required)Does your child have any special problems (health problems, allergies, learning disabili-ties, behavior disorders) a volunteer should be aware of?(Required)Describe your child's school performance including grades, homework, attendance, behaviors, etc.(Required)Is your child currently having any problems either at home or school?(Required)Is the child's non-custodial parent living in the area? Yes No Where?Does he or she visit the child? Yes No How often?Briefly describe their relationship:Would this parent have any objections to your child's participation in Kinship?Do you anticipate any major life changes within the next year? (personal, vocational, or residential)Is there anything else you think would be helpful for the Kinship staff or mentor to know about your child?Parent/Guardian Signature (Type Full Name)(Required)Date(Required)
