BCArc - Protégé Application -

Referral for a Protégé/Mentee

Application

This section to be filled out by the Protégé/Mentee

First Name

Last Name

Address

City

US States

Zip

Date of Birth

Male/Female

Divider

What are your favorite activities/hobbies?

What are the types of activities you would enjoy doing with an advocate/mentor?

Please describe your likes and dislikes.

Please list any preferences you may have concerning your advocate/mentor:

When available

What is the availability of the protégé/mentee for spending time with their advocate/mentor?

Availability

Please suggest specific needs or problems with which an advocate/mentor could assist the individual.

Has Citizen Advocacy/Youth Mentoring been discussed with the individual?

Is the individual their own legal guardian

If No, List name, address and phone

What, if any, physical limitations does this individual have?

Does this individual use special equipment (wheelchair, braces etc.)

What medication, if any, is this individual taking?

Does this individual have any known allergies or other significant medical problems?

Any additional information you would like to provide :