Youth Application /
Contact Information
Name of youth: / Youth home phone: / Youth cell phone: / Youth email address:
Youth street address (please include apartment number, city and zip code):
Parent/Guardian Contact Information
Parent/Guardian name: / Relationship to youth: / Email address:
Home phone number: / Work phone number: / Cell phone number:
Parent/Guardian street address (please include apartment number, city and zip code):
Youth Demographics
Part Three: Demographics
Date of birth / Race & Ethnicity
Mark all that apply.
Gender identity □ Male □ Female / Asian
Black
Hispanic/Latino
Middle Eastern
Multiracial
Native American
Pacific Islander
White
Other: ______ / Optional
If applicable, country/cultural identity:
______
______
Language(s) spoken at home
Household income
Please circle one
<$10,000
$10,000 -- $25,000
$26,000 -- $50,000
$51,000 -- $75,000
>$75,000
Does youth self-identify as having a disability?
/ Is youth comfortable discussing disability-relevant information?
Referral Information
How did you hear about MentorABILITY?
Name of person that referred you to MentorABILITY.
/Name of agency that referred you to MentorABILITY.
Disability Information
At MentorABILITY, we define “disability” very broadly, spanning from physical disabilities to learning disabilities to mental health and health conditions. Please mark all that apply, and provide any additional information as needed.
DevelopmentalAutism spectrum
Down syndrome
Fragile X syndrome
Sensory integration disorder / Intellectual
Brain injury
Cognitive delay / Learning
Auditory processing disorder
Dyscalculia
Dyslexia
Non-verbal learning disorder
Physical
Ataxia
Cerebral palsy
Muscular dystrophy
Scoliosis
Spina bifida / Communication
Aphasia
Language challenge (expressive or receptive)
Non-verbal
Stutter
Tourette / Sensory
Hard of hearing or deaf
Visual impairment or blind
Mental Health
ADHD
Anorexia or bulimia
Anxiety
Bipolar
Depression
Obsessive-compulsive
Post-traumatic stress
Schizophrenia / Health
Asthma
Blood disorder
Cancer
Diabetes
Epilepsy
Immune disorder / Other
Reasonable accommodations needed, or other disability-relevant information:
Allergies, medications, and other relevant medical information.
Additional Information
Please check any and all of the following that apply to the applicant. These categories have been determined by the Office of Juvenile Justice, one of our supporting agencies. Answers to this section are used only to help us make the best potential match and will never exclude the youth from becoming involved in the program. At UCBLN-MentorABILITY, we welcome and include people of all abilities, identities, and backgrounds. We believe that diverse and fully inclusive organizations empower individuals, heal communities, and create a better world for us all.
¨ This youth has shown signs of consciously wanting to avoid or miss school.
¨ This youth has expressed a desire to drop out of school.
¨ This youth has a record of chronically being absent from school.
¨ This youth has shown signs of low achievement or low expectations in their schoolwork.
¨ This youth has been involved in bullying (either as aggressor or victim).
¨ This youth or someone in the youth’s immediate family has been involved in the criminal justice system.
¨ This youth has a history of drug or alcohol use (past or current).
¨ This youth associates with peers you would consider aggressive or delinquent.
¨ This youth exhibits anti-social behaviors or tendencies.
Additional Comments
236 9th Street, Evanston, WY 82930 | 307-783-6302 | www.blnworks.com
adaptedfrom Partners for Youth with Disabilities 2017 3