Kinship Referral Form | Lakes Crisis & Resource Center

This form is to be completed by the referring agency or person and returned to Lakes Area Kinship. Information on this form will be kept confidential and will be used to assist Kinship in matching the child with an appropriate adult volunteer. Please take the time to fill in all information completely to the best of your knowledge.

Date

Referring Agency/Employer

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Person

Title

Phone Number

Child's Data

Name

Home Phone

Child Living With

Relationship to Child

Street Address

City/Town

State/Province

ZIP/Postal Code

Mailing Address

City/Town

State/Province

ZIP/Postal Code

Date of Birth

Ethnic Origin

Gender

Legal Guardian

School/Education Information

School child is currently attending

Grade

Subjects child most enjoys

Participation in school activities

Other Agency Information

Do you know of any other agencies working with this child or family?

If yes, please list any of which you know

Recommendations for Matching

Which mentoring relationship do you think this child would most benefit from?

How do you think an adult volunteer would help this child?

What type of person would you suggest we match with this child?

Is this family expecting contact from Kinship?

Other Comments

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Math question 5 + 3 =

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