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Home
About Us
PROGRAMS
SEMINARS
DONATE – GET INVOLVED
Gallery
Y.O.C.
Contact

CATALYST MENTORING REGISTRATION

Mentoring For Greatness

This is a collaborative effort between the schools and CATALYST Global Youth Initiatives, Inc.

All CATALYST MENTORS are background checked and registered with Volusia County Schools.

The information being requested is being used to provide effective long term mentoring for your child. By providing this information, it allows us to be consistent from beginning to graduation. Your information is never shared with outside agencies or providers.

Step 1. Complete the application below.

Step 2. You must request a mentor from your school’s guidance counselor and complete the school’s mentor application.

We select a mentor based on the information you provide to us. We will notify you when your mentor is available.

Note: Females mentor females and males mentor males.

Request a Mentor

Step 1 of 3

33%

Child's Name*
First Last
Child’s Date of Birth:*
Date Format: MM slash DD slash YYYY
What School does your child attend?*
Parent/Guardian Name:*
Parent / Guardian's Email*
Relationship to Youth:*
- Mother
- Father
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone:
Work phone:
Cell:*
Youths Age:*
Gender:*
- Male
- Female
Ethnicity:*
- White
- Hispanic
- African American
- Asian
Grade Level:*
- 5
- 6
- 7
- 8
- 9
Emergency contact:*
Emergency Relationship to youth:*
T-shirt size:*
- XS
- S
- M
- L
- XL
- XXL

3. Describe your youth’s school performance
Grades*
- Above Average
- Average
- Below Average
Homework*
- Above Average
- Average
- Below Average
Attendance*
- Above Average
- Average
- Below Average
Behavior*
- Above Average
- Average
- Below Average
4. Is your youth currently having any problems either at home or school?*
- Yes
- No
5. Has your youth experienced any traumatic events (i.e., death in the family, abuse, divorce within the last 2 years)? If yes, please provide details.*
- Yes
- No
If yes, please provide details
6. Can you provide any additional background information that may be helpful in building a healthy relationship with you and your family?*

Does your youth have any physical problems or limitations?*
- Yes
- No
Is your youth currently receiving treatment for any medical issues?*
- Yes
- No
Does your youth have any emotional issues or problems right now?*
- Yes
- No
Is your youth currently seeing a counselor or therapist?*
- Yes
- No
Does your youth have any allergies?*
- Yes
- No
If yes, please specify
The Parent(s)/Guardian hereby authorizes release of educational records such as report cards, grades, assessment data, homework assignments, and other related academic achievement records to the CATALYST Mentoring for the purpose of assisting in the youth’s school success. Information will remain confidential and will only be used for educational and advocacy and planning purposes.*
- I agree
The Parent(s)/Guardian hereby agrees to allow the CATALYST to use any photographic image and/or digital media of my youth taken while participating in any and all program activities. These images may be used in promotions or other related marketing materials.*
- Agree
By entering your name below, you are effectively providing your signature, indicating that you attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.*
- I agree
Parent/Guardian Signature
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

1309 Michael Avenue
Deltona, Fl 32738

contact@catalyst2010.org

(833) 473-6660

@2022 CATALYST GLOBAL YOUTH INITIATIVES, INC.