Child Referral Form for Parents
- La Crosse Area
Community Based Mentoring
Emerson (La Crosse) Surround Care
Northside (La Crosse)
Hamilton (La Crosse)
Lawrence-Lawson (Sparta)
West Salem Elementary
Erickson Boys and Girls Club
Mathy Center Boys and Girls Club
Ho-Chunk Nation Youth and Learning Center
I am referring a child for:
(Click on the community based
or the site based mentoring
location the child attends.)
Your First and Last Name:
Your Relationship to the Child:
Home phone
Cell phone
Work phone
Your Phone Number:
Home phone
Cell phone
Work phone
Alternate Phone Number:
Your Email Address:
Home phone
Cell phone
Work phone
Email
Best way to contact me:
Best time to contact me:
Child's First and Last Name:
Child is:
Female
Male
Child's Date of Birth (m/d/yyyy):
Child's Address:
Child's City, State and Zip Code:
Additional information about the child
you think we should know:
