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Home
About Us
Services
Small Business
Mental Health & Wellness
Family Services
Youth Services
Career Development Services
Housing & Homelessness
Programs
Events
DONATE
Get Involved
Download the application using the button below, or complete the application electronically right here on this page.
Apply to Y.O.U.T.H Program
Applicant Type Section 1
Adult Mentor (Sections 2, 3, 7, 8)
Ages 25 +
Young Adult Coordinator ( college aged ) (sections 2, 4, 7, 8 )
Ages 18 - 24
High School Participant ( section 2, 5, 7, 8)
9th and 10th Grade
High School Participant ( section 2, 5, 7, 8 )
6th and 8th Grade
Basic Information Section 2
Name:
Full name of the person filling out the form ( if not applicant):
Phone:
Email Address:
Emergency Contact Name:
Relationship to Applicant:
Child's Name ( if applicable):
Emergency Contact Phone:
Street Address:
City:
State:
ZIP / Postal Code:
Adult Mentors Section 3
Why do you want to serve as a mentor in the Y.O.U.T.H Program?
Describe your experience working with youth?
Describe your experience working with youth?
Areas Of Expertise:
Check all that apply
Academic Training
Career Guidance
Emotional Support
Leadership Development
Arts
Sports
Technology
Other
Are you able to commit to weekly mentoring sessions?
Yes
No
Have you ever completed a background check?
Yes
No
Are you willing to undergo a background check?
Yes
No
Section 4 Youth Adult Coordinator ( college age applicants only )
College or University attending or graduated from:
Major or Area of Study:
Describe your leadership or mentoring experience.
Why do yo want be a coordinator in the Y.O.U.T.H Program?
Are you comfortable facilitating youth group activities?
Yes
No
Skills you bring to the program?
Section 5 High School Participants
Name of High School:
Grade Level:
9th Grade
10th Grade
11th Grade
12th Grade
What do you hope to gain from the Y.O.U.T.H Progragram?
Interest and hobbies:
Section 6 Middle School Participants
Name of Middle School:
Grade Level:
6th Grade
7th Grade
8th Grade
12th Grade
Why would you like to join the Y.O.U.T.H Program?
Interest and hobbies:
Parent / Guardian Name:
Parent / Guardian Phone Number:
Section 7 Photo / Video Release
All Applicats or Parents of Minors
I give permission for my ( or my child's ) image to be used by SMBEA for education, documentation and promotion purposes.
*
Yes
No
Section 8 Participation Agreement
I acknowledge that participation in Y.O.U.T.H program requires respectful behavior, postive engagement , and adherence to the SMBEA program guidelines
I acknowledge that participation in the Y.O.U.T.H Program requires respectful behavior, postive engagment, and adherence to SMBEA program guidelines.
*
Yes
Area to sign
Optional to upload your signature.
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Submit Application
