CHAMPS Mentoring

Referral Form

 

Please complete the following and mail it to the address below.

 

           Child’s Name __________________________________________

 

           Parent’s Name __________________________________________

 

           Address _______________________________________________

                                  (Youth referred must be a Perry County resident)

 

           Home Phone ___________________________________________

 

           Work Phone ____________________________________________

 

 

Mail to:

Perry County Community Task Force

406 N Spring, Suite 4

Perryville, MO  63775

Back to CHAMPS Mentoring

If you are referring your own child you will also need to complete the following forms:

 

           Letter of Permission

 

           Checklist of Needs

 

           Interest Inventory

Helping Today’s Youth Become Tomorrow’s Leaders.

Perry County Community Task Force