Child Referral Form

Thank you for your partnership!

Your referrals help connect students with caring mentors, providing them with additional friendship, guidance, and encouragement. Please use this form to refer students who could benefit from a one-to-one mentorship opportunity. We appreciate all you do to help youth reach their full potential!

ALL INFORMATION WILL REMAIN CONFIDENTIAL

Questions? Contact us

info@bbbssmn.org

507.451.5922

bbbssmn.org

Child Demographics

Child Name

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Gender

Birthday

Ethnicity

Address

City

State

Zip Code

School

Grade

Parent/Guardian Information

Parent/Guardian Name

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Parent/Guardian Phone

Parent/Guardian Email

Relationship to Child

Is their parent/guardian aware you are making this referral?

YesNo

Is their parent/guardian in need of a translator? If yes, please specify language.

Referred by: