Hours of Operation

Monday - Friday 8:00am - 9:00pm with the exception of Wednesday the clinic is open from 8:00am - 12:00pm, and 5:00pm - 9:00pm.

Saturday - 9:00am - 1:00pm

Patient Satisfaction Survey

Youth Mentoring Program

Contact and Information Release

(To be Completed by the Parent/Guardian}
Youth's Name: Date:
School:
I hereby grant permission for Youth Mentoring Program to make contact with my child and conduct a personal interview for the purposes of applying to be a mentee.    Youth Mentoring Program staff may also make contact with my child on school premises for the purposes of screening and interviewing as well as ongoing support of his/her participation in the Mentoring program.

I authorize Youth Mentoring Program staff to obtain any needed information regarding my child from his/her school’s staff, including academic and behavioral records and conversations with teachers, counselors, and other administrative staff.

Further, I understand that basic information about my child will be anonymously (without names) shared with a prospective Mentor(s) to aid in determining a suitable match. Once a Mentor/Mentee match is determined, my and my child’s identity and other relevant information will be shared with the Mentor to the extent it aids in facilitating a successful match.

Parent/Guardian Signature
Date

Parent/Guardian Name:		  
Street Address:  
City: State: Zip: