Richland-Wilkin
509 ½ Dakota Ave Suite 104 Wahpeton, ND 58075
701-672-0303
E-mail: rwkinship@702com.net rwkinship.org
Dear Parent(s),
I understand you are interested in learning more about the Kinship Program
with the possibility of having your child participate in the program.
Let me tell you more about it. First of all, the program is very similar to a
Big Brother/Big Sister Program where an adult is matched with a child based
on their common interests and needs. Any child age 5-16 that would benefit
from extra adult support is welcome to participate. The adult who is
matched with a child is expected to provide an average of one hour a week
of companionship to the child for a commitment of one year.
If you wish to have your child participate in the Kinship Program, please
complete the enclosed forms. After a careful and thorough selection
process of identifying volunteers, I then make a match between your child
and a compatible adult based on the information you provided. You and your
child will get to meet the adult before the match is made. I then
communicate regularly with everyone involved to ensure things are going well.
I must caution you that I cannot guarantee an immediate match with your
child since making compatible matches depends on the number of volunteers
there are. Unfortunately, there are usually more children on our waiting list
than there are adults, but I am working hard to recruit volunteers.
If you have any questions, please contact me at the number listed on the
forms. Please fill out the enclosed forms and return to the above address.
Regards,
Jeff Bass/Rebekah Christensen Program Coordinators
Richland-Wilkin
Jeff Bass/Rebekah Christensen 509 ½ Dakota Ave Wahpeton, ND 58075
rwkinship@702com.net rwkinship.org 701-672-0303
Supported by the Wilkin County Governing Board & Children’s Cabinet, Bremer Foundation and United Way of Richland-Wilkin
YOUTH APPLICATION
Youth Name________________________________________ Birth Date____________ Age______
Youth Email________________________________________________________________________
Parent’s Name ____________________________________________________Phone____________
E-mail ____________________________________________________________________________
Address___________________________________________________________________________
Employment ______________________________________________________Phone____________
Brothers and Sisters: Name _______________
Age______
Name_______________ Age____
Name _______________
Age ______
Name _______________ Age ____
School _____________________________________________________________________________
Current Needs or Challenges__________________________________________________________
_____________________________________________________________________________________
PARENTS INFORMATION
Please answer all questions to the best of your ability.
The success of the Kinship Program depends on the SUPPORT OF THE PARENT.
1. How did you learn about Kinship?
2. Were you referred by an individual?
If so, who?
3. How do you think your child would benefit from having a mentor?
4. My child is in counseling/treatment_____________
My child has had counseling/treatment __________ Please Explain:
5. What are special needs or interests that a volunteer can help your child with?
6. Are there any issues at home, school, etc. that we should be aware of?
7. Describe your child: (example: quiet, shy, active, etc.)
8. Please check: Are you Married ______ Divorced _______ (how long)_____________
Separated________ Widowed _______ Other ______________
9. If you are a single parent:
(a) Is child’s other parent in the area? _______________________________________
(b) Does the child see his/her other parent? ___________________________________
(c) If so, how often? _____________________________________________________
(d) Do you anticipate any objection from this parent regarding Kinship?
___________________________________________________________________
10. I do ____ do not _____ give my permission for my child’s picture to be taken and displayed
for the promotion of the Kinship program.
Kinship is a mentoring program for youth who would benefit from additional adult support. It is not to
be used as a babysitting service. With your cooperation and everyone working together, this mentoring
program can be a rewarding experience for your child.
I UNDERSTAND THE NATURE OF THE KINSHIP PROGRAM AND PLEDGE MY SUPPORT IN
HELPING THE FRIENDSHIP GROW. I AGREE TO ALLOW MY CHILD TO PARTICIPATE.
PARENT’S SIGNATURE __________________________________________________________
Date: __________________________________________________________________________
*We would like a photo of your child if you have one. (Not necessary for application).
PLEASE RETURN TO ADDRESS ABOVE
Richland-Wilkin
Jeff Bass/Rebekah Christensen 509 ½ Dakota Ave Wahpeton, ND 58075
rwkinship@702com.net rwkinship.org 701-672-0303
Supported by the Wilkin County Governing Board & Children’s Cabinet and United Way of Richland-Wilkin (Richland Co., ND & Wilkin Co., MN
MEDICAL RELEASE FORM
I hereby authorize
________, a mentor for Richland Wilkin
Kinship, to secure emergency medical attention for my son/daughter
_______________________________________, in the event I cannot be contacted.
Our local Doctor:
Phone:
Address
has my
permission to release any records that may be needed to treat my son/daughter in an
emergency.
For emergency purposes, I can be reached at Home Phone:
Work Phone:
Emergency Contact:
Cell #:
Phone:
Allergies:
Drugs which my child should not be administered are:
__________________________
Phobias (fears, etc.)
Any other pertinent medical information, i.e current medications my son/daughter is
taking:
If on Medical Assistance/Insurance/HMO, please give number to used
Signature
Date
ACTIVITIES AND INTERESTS SURVEY
Please circle the activities you enjoy or would like to try.
Professional sports
College sports
High school sports
Camping
Football
Baseball
Basketball
Track
Badminton
Soccer
Ping Pong
Tennis
Volleyball
Bike Riding
Roller Skating
Bowling
Pool
Swimming
Wrestling
Hockey
Figure Skating
Cross country skiing
Sledding
Woodworking
Walking
Croquet
Drawing
Fishing
Picnicking
Boating
Canoeing
Water Skiing
Model Building
Carving
Video Games
Television
Movies
Museums
Concerts
Reading
Singing
Cooking
Painting
Writing
Crafts
Dancing
Circus
Animals
Snowmobiling
Dolls
Talking
Art fair
State Fair
YMCA
Playing Cards
Music
Indoor Games
Collections/What
Auto Mechanics
Animal Tending
Horses
Gardening
Hair/Makeup
Auto Racing
Handball
Golf
Other: _________
What are your favorite/special interests or activities? _____________________
________________________________________________________________
Is there anything you dislike or cannot do? ______________________________
________________________________________________________________
Is there anything new you have been hoping to learn to do? ________________
________________________________________________________________
Name _______________________________________ Date ______________