Agency Partners

Personal Information

We ask that you complete the following application as thoroughly as possible. Be assured this information is confidential.

Child's Name *

Home Address *

Mailing Address (if different)

City *

State *

Zip *

Child's Gender *

Male

Female

Date of Birth *

Birthplace *

Ethnicity *

Religious Affiliation

Primary Language *

Secondary Language (if any)

School *

Grade *

Does you child participate in free/reduced lunch? *

YES

NO

How does your child feel about being enrolled in the M4K Program? *

Parent/Guardian Information

How did you learn about our Mentoring 4 Kids Program? *

Parent/Guardian Name *

Age

Relationship to Child *

Phone Number (Preferred Contact Number) *

Email *

Are you presently employed? *

YES

NO

Business/Employer Name and Address

Occupation

What hours do you work?

May we contact you at work?

YES

NO

Highest level of education completed. *

How long have you lived in Palm Beach County? *

Do you anticipate any changes of address in the coming year? *

YES

NO

If yes, where?

Child and Family Information

Have you or your child received any professional help from other agencies, schools, psychiatrists, psychologists, social workers, etc? *

YES

NO

If yes, please list agency name, address and the professional you worked with.

Would you allow us to contact any of the above professionals?

YES

NO

Has your child ever lived away from your home? *

YES

NO

If yes, please tell us where, when and for how long.

Marital Information

Spouse Name

Date of Marriage

Date of Termination

Reason: (death, divorce, etc.)

Spouse 2 Name

Date of Marriage

Date of Termination

Reason: (death, divorce, etc.)

Absent Parent Information

Name *

Age

Address

Phone

Does he/she have contact with the child? *

Yes

No

If yes, how often?

When did child last see absent parent? *

Does absent parent have legal visiting rights? *

Yes

No

List All Persons Now Living In Your Household

1. Name, Relationship to Child, Age

2. Name, Relationship to Child, Age

3. Name, Relationship to Child, Age

4. Name, Relationship to Child, Age

5. Name, Relationship to Child, Age

6. Name, Relationship to Child, Age

Total Household Income (please check one) *

Statements & Policies:

Your signature (typed name) below indicates that you have read, understand, and agree with the statements and policies found on this form.

POLICY on CONFIDENTIALITY: In order for Mentoring 4 Kids, a program of Jewish Family & Children’s Service of Palm Beach County, Inc., to provide a responsible and professional service to clients, it is necessary for volunteers, clients, and parents or guardians of clients to be asked to divulge extensive personal information about themselves and their families. Jewish Family & Children’s Service respects the confidentiality of client and volunteer records, and with the exception of the limits of confidentiality, shares information about clients and volunteers only among the agency professional staff. The exceptions that define the limits of confidentiality are available, if requested. The right to confidentiality applies not only to written records, but also to video, film, pictures or use of client or volunteer's names in agency publication. All records are considered the property of Jewish Family & Children’s Service and not the agency workers of clients or volunteers themselves. In order to provide a service which is in the best interest of the children served by the program, information from outside sources, including confidential references must be assessed along with information gained from the clients or volunteers themselves. Records are, therefore, not available for review by the clients or volunteers. Clients and volunteers shall be provided, at the time of application, a copy of this statement on confidentiality. Clients and volunteers shall sign a statement that he/she has read and understands the Jewish Family & Children’s Service policy on confidentiality and agrees to program participation under the guidelines it sets forth. I have read and understand the above document which states the Jewish Family & Children’s Service policy with respect to confidentiality of client and volunteer records. I agree to program participation under the conditions it sets forth. (Please enter your full name) *

I hereby make formal application to Mentoring 4 Kids, a program of Jewish Family & Children’s Service, a non-profit Florida corporation, to make available the services of Mentoring 4 Kids to my child, and if possible assign to him/her a competent adult volunteer. I understand in determining whether my child is appropriate for services, information about the family history, health, personalities and behaviors will be explored. I hereby release Jewish Family & Children’s Service of all responsibilities and liabilities in connection therein. I hereby understand that in matching a child with a volunteer, Mentoring 4 Kids will share certain relevant information about the child with the prospective mentor. The name of the child, however, shall remain confidential until the parent has been introduced to the volunteer. A similar profile of the volunteer will also be shared with parent or guardian. Any party has the right to refuse to enter into the match based upon information communicated. I agree not to share the information with any other person. (Please enter your full name) *

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