Child Enrollment Referral | In School | LSS Mentoring Services

We're glad you're here!

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 by completing the form below.

If you do not receive a confirmation email within 48 hours, please contact LSS In-School Mentoring at 605-444-7803.

Parent First Name

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

yrgl0tsy90a2

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 with whom 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 with? (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

In-School Mentoring Referral

We're glad you're here!

Matching Information