Refer A Child You Know

Not a parent or guardian? Refer a child you know here. Do you know a child between the ages of 7-16 on Long Island that could use a mentor? Please fill out our quick referral form and we’ll get back to you. Thank You!

Realize their Potential

Referrer's Information
Referrer's Name*
First Last
Referrer's Relationship to the Child*
Referrer Phone Number
Referrer Email*
Guardian Information
Guardian Name*
First Last
Guardian Address*
Street Address Address Line 2 City State ZIP Code
Guardian Phone*
Guardian Email
Child's Information
Child's Name*
First Last
Child's Date of Birth*
Gender*
Does the child have any physical, mental or behavioral challenges?*
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Refer A Child You Know

Realize their Potential

Referrer's Information

Guardian Information

Child's Information

Nassau

Suffolk

Your Information