Code Switch: Mentee Interest/Referral Form

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Thank you for your interest in Code Switch. Please use this form to refer girls to our mentorship programs. We will reach out to the family and student by phone and email once your referral is received. Youth can also refer themselves. Keep in mind, Code Switch youth must meet the following criteria:

Be 11-21 years of age
Speak and understand English
Live in Southern Nevada
Enrolled in a K-12 area middle or high school (not home-schooled)
Give written assent (agreement) to participate
Have written consent from a parent/legal guardian to participate ( required if under 18)
Self-Identify as a Girl/Young Woman of Color wanting mentorship and support through Code Switch programs
Be referred to the program by a parent, legal guardian or caregiver; appropriate school-based professional, or affiliates with a Code Switch community-based partner

Email *

First and Last Name of Individual Making the Referral: *

Role & Organization: *

Relationship to Referent: *

Parent/Caregiver/Legal Guardian

Teacher

School Counselor/Social Worker/Psychologist

Mentor

Community-Based Organizational Advisor/Case Manager/Support Provider

Other:

Best Contact Phone Number (required): *

Type of Referral: *

Partner School

Harbor/Courts

Partnering Organization

Parent/Caregiver/Legal Guardian

Self (Interested Girl or Young Woman of Color)

Other:

Reason for a Referral (check all that apply) *

School-based Discipline

Court Involved

Request/Desire Mentored Support

Interest in Developing Leadership Skills

Self Empowerment & Self Concept Development

Seeking Peer Group Support

Academic, College, and Career Track Development

Interest in Youth Based Restorative Justice and School-to-Prison Pipeline Advocacy

Interest in Youth-Led Social Action and Movement Building

Other:

Required

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