A Project of Nevada Partnership for Homeless Youth
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Youth Interest Form
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Youth Interest Form

This form is for youth who are interested in joining Power ON!

If you are in immediate danger, please call 911.

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

Full Name (required):

Preferred Name (if different than above):

Date of Birth: (required)

Age: (required)

Gender Identity:

Race:

Street Address:

City:

State:

Zip Code:

School:
"Power ON! will never contact you at school or contact your school regarding you. Please place N/A if you have stopped attending school or dropped out.”

How did you hear about this program?

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):

Social Media Handle:

Please provide the best contact for your parent/guardian. If your parent(s)/guardian(s) cannot or should not be contacted for any reason, please explain:

What is your living situation?

What goals would you like to accomplish this year?

Why are you interested in getting a Power ON! Mentor?

What are some of the biggest challenges in your life?

Has anyone ever pressured you to engage in any sexual acts against your will?
YesNo

Do you have a history with the juvenile justice system?
YesNo

Do you have a history with the foster care system?
YesNo

Do you identify as LGBTQ?
YesNo

Have you ever traded sex for money, food or shelter?
YesNo

Have you ever run away from home?
YesNo

Did you drop out of school?
YesNo

Have you ever been or are you currently involved in a gang?
YesNo

Are you homeless?
YesNo

Have you 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 with 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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