Mentor Application- Referral — Reclaiming Our Roots

Referral Mentorship Application

Thank you for your interest in referring a youth to on the land mentorship with Reclaiming Our Roots. Please fill out this application to the best of your ability and we will be in contact to see if this opportunity is a good match for all of us.

Who is making this referral?

Name

First Name

Last Name

Name of your organization

Relationship to the youth

Phone

(###)

###

####

Did you discuss this opportunity with the youth you are referring?

It is essential that mentoring youth are personally excited and invested in this opportunity. Did your youth express an interest in this learning independently?

If youth is under 18:

Parent/Guardian Info

Parent/Guardian e-mails:

Parent/Guardian Phone

(###)

###

####

Emergency Contact Name

Relationship to youth:

Emergency Contact Number

Country

(###)

###

####

Youth Information

Name

First Name

Last Name

Preferred name (if different)

Pronouns (if known)

Birth date

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Self-Identification

Status First Nation

Non-Status First Nation

Métis

Inuit

African Nova Scotian

Black/African Descent

Other

Unsure

Nation(s)/Communit(ies)

Please tell us about the communities that you know of that this youth is connected to. This can include one or more reserves, urban or rural Indigenous communities, non-Indigenous identities, or "still learning".

Health Card Number

If you don't have this information right now, or prefer not to give it, we can wait until the youth is accepted as a mentor and goes on their first outing.

Expiry

YYYY

Youth Information

Please tell us about the youth you are referring: personality, interests, strengths, challenges, etc. How would you describe this youth?

Why do you think a land based learning mentorship would be a good fit for this youth?

Do you have any concerns about this youth participating in a mentorship? What barriers or challenges would this youth experience to accessing this knowledge without this mentorship?

This will not be used to determine if your youth will be accepted, it's just so we can understand what we need to do to best support your young person. We want to support young people in challenging situations.

Are there any health or accessibility needs we should know about?

Are you or your organization able to partner with Reclaiming Our Roots to cover the costs of some clothing/gear if necessary?

Most often this is warm boots or other outdoor clothing.

We try our best to capture special moments and milestones through photos. With permission, we may share some of these on our social medias. If this youth is under 18 and you are their legal guardian, do we have your permission to take and share photos of this young person?

If your youth is over 18 or you are not their legal guardian, please leave blank.

Is there anything else we should know ?

Thank you!

Referral Mentorship Application

RECLAIMING OUR ROOTS