Caregiver Application

Application to become a Caregiver

Step 1 of 5

Parent/Caregiver Application

How Did You Hear About Seton Youth Services?(Required)

Please share how you heard about Seton. If someone referred you, please include their name.

Youth's Name(Required)

First Last

Youth's Birth Date

Parent/Caregiver's Name(Required)

First Last

Relationship to Youth(Required)

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Best Contact Number(Required)

May We Text You?(Required)

Yes

Parent's Information

Sex of Parent

Male

Female

Birthdate of Parent

Race of Parent

Parent's Primary Language

Other Languages Spoken by Parent

Please provide any employment information:

Name of Employer

Work Phone

Alternative Contact Information

Please provide alternate contact numbers to reach you, only if we are unable to reach you with the telephone numbers listed above (friend, family member, neighbor)

Alternative Contact Name

First Last

Alternative Contact Relationship

Alternative Contact Telephone Number

Alternative Contact Name

First Last

Alternative Contact Relationship

Alternative Contact Telephone Number

Alternative Contact Name

First Last

Alternative Contact Relationship

Alternative Contact Telephone Number

Signature

Today's Date

Please read this carefully before signing:

Seton Youth Services MCP Program appreciates you and your child’s interest in his/her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their son/daughter to participate in the Seton Youth Services MCP Program. After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your child has been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match your child with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.

Please initial each of the following:

I give my informed consent and permission for my child to participate in the Seton Youth Services’ MCP Program and its related activities.(Required)

I agree to have my child follow all mentoring program guidelines and understand that any violation on my child’s part may result in suspension and/or termination of the mentoring relationship.(Required)

I hereby acknowledge that my child will be transported by his/her mentor and/or Seton Youth Services’ staff or representatives while participating in the Seton Youth Services’ MCP Program, and that such transportation is voluntary and at his/her own risk.(Required)

I release the Seton Youth Services’ MCP Program of all liability of injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Seton Youth Services mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.(Required)

I attest that my child has been affected by incarceration.(Required)

I understand that Seton Youth Services might host group events that my child may attend. I understand that it is my sole discretion whether or not my child may attend these outings as the Seton Youth Services’ Mentoring Children of Prisoners name may be used at these group outings.(Required)

I understand I must return all of the completed items along with this application, and that any incomplete information will result in the delay of my application being processed.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Parent/Guardian Signature(Required)

Date

Family History

Biological Mother

First Last

City & State

Home Phone

Cell Phone

Biological Father

First Last

City & State

Home Phone

Cell Phone

Step/Adopted Mother

First Last

City & State

Home Phone

Cell Phone

Step/Adopted Father

First Last

City & State

Home Phone

Cell Phone

Siblings:

Sibling Name

First Last

Age

Sibling Name

First Last

Age

Sibling Name

First Last

Age

Sibling Name

First Last

Age

Name

First Last

Age

Sibling Name

First Last

Age

Sibling Name

First Last

Age

Sibling Name

First Last

Age

Caregiver Application

Parent/Caregiver Application

Parent's Information

Alternative Contact Information

Please read this carefully before signing:

Please initial each of the following:

I understand I must return all of the completed items along with this application, and that any incomplete information will result in the delay of my application being processed.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Family History

Siblings:

Seton Youth Services Mentoring Program Medical History and Authorization for Emergency Medical Services

General Health Review

Family Medical History

Authorization to Initiate Emergency Medical Services

Contact Us

(757.498.HELP)

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Client Privacy Statement

Caregiver Application

Caregiver Application

Parent/Caregiver Application

Parent's Information

Alternative Contact Information

Please read this carefully before signing:

Please initial each of the following:

I understand I must return all of the completed items along with this application, and that any incomplete information will result in the delay of my application being processed.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Family History

Siblings:

Seton Youth Services Mentoring Program Medical History and Authorization for Emergency Medical Services

General Health Review

Family Medical History

Authorization to Initiate Emergency Medical Services

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Contact Us

(757.498.HELP)

Connect Via Facebook

Client Privacy Statement