REFER A YOUTH

Rogue Valley Mentoring offers one-to-one mentoring matches and a variety of community programs, serving youth ages 9 to 24 years old. Are you a school, healthcare, mental health, government, or community partner employee who knows a youth who would like a 1-to-1 mentor, or is looking for a community of youth to join?

FILL OUT THIS FORM!

Please let us know who we can reach out to, and what program they are interested in!

RVM program staff will reach out to the youth or their parent/guardian to answer any questions they may have and to invite them to apply using the program application/registration form.

Have Questions? Contact us!

info@rvmentoring.org

(541) 708-6688

FILL OUT THIS FORM TO REFER A YOUTH

Referring Agency

Referring Party Name

Referring Party Contact: Phone

Referring Party Contact: Email

Youth First & Last Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender

Youth's Parent/Guardian Name

Parent or Guardian's Email

Parent or Guardian's Phone Number

What RVM programs is the youth interested in? Please, check all that apply:

1-to-1 Mentoring (9 - 24 year old youth)

Youth Leadership Advisory Board - YLAB (11 - 21 year old youth)

UNIDOS After School Program ( Phoenix/Talent middle school youth, BIPOC and allies).

Other

Please tell us why you would like to refer this youth, and anything else RVM should know prior to making contact.

By submitting this form, you give permission for Rogue Valley Mentoring to contact the parent or guardian of the interested youth regarding this opportunity.

Yes, I agree.