Youth Group
Application

Thank you for taking the first step toward connecting a young person with our group mentoring program. Mad River Mentoring brings youth together in a supportive setting, pairing small groups with caring mentors for shared experiences and lasting growth.

Mad River Mentoring is committed to fostering an environment of diversity and inclusion for all. Eligibility will not be determined based on race, color, gender, sexual orientation, or disability. Our program director will be in touch with next steps after this application has been submitted.

There are no groups currently open for registration. Please check back soon or contact us at info@madrivermentoring.org.

About You

Tell us a little about yourself — the person filling out this application.

First Name *

Last Name *

Email Address *

Phone Number

Your relationship to the youth *

About the Youth

First Name *

Last Name *

Preferred Name (if different)

Date of Birth *

Youth must be between 8 and 17 years old to apply.

Gender Identity

Pronouns

About the Application

What group is your child signing up for? *

There are no groups currently open for registration. Please check back soon or contact us at info@madrivermentoring.org.

How did you hear about Mad River Mentoring? *

Why would the youth like a mentor? *

In the youth's own words if possible — what are they hoping to gain from this program?

Interests & Activities

What does the youth enjoy doing? Sports, hobbies, creative interests — anything that helps us find a great match.

Health & Medical

This information helps us ensure the safety and wellbeing of the youth. It is kept confidential and shared only with matched mentors on a need-to-know basis.

Does the youth have any allergies? *

Yes No

Other relevant medical or health information

Any diagnoses, medications, or physical limitations a mentor should be aware of. Leave blank if none.

Household & Custody

Adults in the household

Please list the adults who live with the youth (name and relationship).

Is there a custodial or court agreement in place? *

e.g. custody order, guardianship agreement, DCF involvement

Yes No

Primary Guardian

The primary guardian is the parent or legal guardian who will be the main point of contact for this youth.

First Name *

Last Name *

Email Address *

Personal Phone *

Work Phone

Best times to call

Emergency Contact

Please provide a secondary contact — someone other than the primary guardian — who can be reached in an emergency.

First Name *

Last Name *

Relationship to Youth *

Cell Phone *

Work Phone

Review & Submit

By submitting this application, I certify that all information provided is true and accurate to the best of my knowledge. I understand that Mad River Mentoring will use this information to find a suitable mentor match and that it will be kept confidential.

I am authorized to submit this application on behalf of the youth named above, and I consent to their participation in the Mad River Mentoring program.

Youth GroupApplication

About You

About the Youth

About the Application

Health & Medical

Household & Custody

Primary Guardian

Emergency Contact

About the Youth — Demographics

Review & Submit

Youth Group
Application