Youth
Application

Thank you for taking the first step toward connecting a young person in your life with a caring, one-on-one mentor. Mad River Mentoring builds lasting relationships that help youth grow in confidence, develop new skills, and feel supported in their community.

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.

About You

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

About the Youth

Youth's Home Address

About the Application

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.

Household & Custody

Primary Guardian

The primary guardian is the parent or legal guardian who is submitting this application and will be the main point of contact.

Emergency Contact

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

About the Youth — Demographics

This information is collected for grant reporting and program evaluation only. All fields are optional and will not affect the application. Your responses are stored securely and encrypted — they are never shared and are only accessible to the Mad River Mentoring program director in the course of program administration.

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.