Child Enrollment Referral | In School | LSS Mentoring Services

If you’d like to explore bringing our mentoring program to your school district, we’d love to hear from you!

School counselors can make a referral for a child to sign up for an in-school mentor.

If you do not receive a confirmation email within 48 hours confirming the application went through successfully, please contact LSS at 605-444-7803.

Fill Out the Application to Enroll a Child in In-School Mentoring

Parent First Name

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Parent Last Name

Child First Name

Child Last Name

Child Birth Date

Child Gender (identifies as):

male
female

Child Home Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Parent Home Phone

Parent Cell Phone

Parent Email

Preferred contact method:

Phone call
Text
Email

Child School

Child Grade Level

Child Primary Language

Does the child spend significant time at a different residence

If yes, please indicate who with and the relationship

If yes, please indicate the address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Emergency contact name

Relationship

Phone

Matching Information

Please list any other information about your child you feel would be helpful in matching them. This can include any special hobbies, talents, or interests.

Please describe a few things your child would like to do when participating in this program.

Why are you interested in this program for your child?

Any issues of concern to note (family history, physical/mental health issues, health conditions)?

What other community programs is your child involved? (sports, clubs, lessons, after-school programs, church, etc.)

By signing, you understand that you hold your child's school district, its schools and staff, and Lutheran Social Services of South Dakota, its staff and mentors, free of liability in the event of any results or developments occurring as part of their efforts on your behalf or the behalf of your son/daughter/guardian student. Thank you!

Typed Parent/Guardian Signature

Date

Administration

In-School Mentoring Referral

Fill Out the Application to Enroll a Child in In-School Mentoring

Matching Information

Administration