A Project of Nevada Partnership for Homeless Youth
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Youth Interest Form
Parent/Guardian Interest Form
Service Provider Interest Form
Parent/Guardian Interest Form

Power ON! is a community mentoring program that strives to empower youth to live a life filled with confidence, safety and self-respect. Once your child becomes a Power ON! Mentee, they will be matched with a trained community Power ON! Mentor, for a one-year mentorship. Throughout the mentorship, Power ON! Mentees will have direct access to the community resources they need and a safe environment, while building a relationship with a trained Power ON! Mentor. As a Power ON! Mentee, your child will begin a journey designed to emPOWER them to become their best self. If you are interested in your child becoming a Power ON! Mentee, please fill out the questions below. The following questions are designed to understand your child’s needs so that we can match them with the proper mentor and services.

Parent/Guardian Information:


Full Name (required):

Relationship to youth:

When is the best time for a Power ON! Match Support Specialist to contact you about this program?
MorningAfternoonEvening

How would you like to be contacted?
PhoneEmailSocial Media

Phone (required):

Email (required):

Youth Information:


Youth Full Name (required):

Youth Preferred Name:

Date of Birth (required):

Age: (required)

Gender Identity:

Race:

Address:

Zip Code:

School (please write N/A if youth has stopped attending school or dropped out):

What is your child's living situation?

When is the best time for a Power ON! Match Support Specialist to contact the youth?
MorningAfternoonEvening

How would the youth like to be contacted?
PhoneEmailSocial Media

If Social Media, please name and add handle:

Is there any evidence or reason to believe that your child is a victim of Commercial Sexual Exploitation and/or Domestic Sex Trafficking?
YesNo

Does the youth have a history with the juvenile justice system?
YesNo

Does the youth have a history with the foster care system
YesNo

Does the youth identify as LGBTQ?
YesNo

Has the youth ever traded sex for money, food or shelter that you know of?
YesNo

Has the youth ever run away from home?
YesNo

Has the youth dropped out of school?
YesNo

Has the youth been involved with a gang or is currently active in a gang?
YesNo

Is the youth currently experiencing homelessness?
YesNo

Has the youth experienced or witnessed physical, sexual, emotional, or mental abuse?
YesNo

Permission:

Thank you for completing this Power ON! interest form! By submitting this form, you are giving permission for Power ON! to have the information stated above. This also gives Power ON! permission to contact you through the contact information provided. We look forward to meeting you!

Please type your name (required):

This serves as your electronic signature.

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