Bona Buddies Youth Mentoring Program

Bona Buddy Youth Mentoring Program is open to all children from pre-school to sixth grade. Children are matched one-on-one with a trained St. Bonaventure
student mentor. Children spend one afternoon a week enjoying a variety of enrichment activities on the St. Bonaventure Campus. A healthy snack is provided.
Contact information: (716) 375-2697 Email: bonabud@sbu.edu
Program Manager: Jeffrey Sved, (716) 375-7813 Email: JSved@SBU.edu
Child/Youth Information
Name: Phone:
Date of birth: Race (for funding purposes only): ______ Circle: Male Female
Current address: School: ______________
Grade: ______________
Academic concern? Yes No
Availability: M T W TH FR 4-6 Circle all that apply
Parent Information
Parent/Guardian Name: _________________________________ Relationship: _____________________
Primary Phone: ________________________ Secondary Phone:__________________
Email: _______________________________

Emergency Contact Information

Name of a contact not residing with you: __________________________
Relationship: ______________________
Phone: ___________________________

General Background Information

Tell us about your child. What are some special interests and hobbies that this youth has?

School History (including name of school, behavioral issues, academic and social concerns):

Is there anything important we should know? If so, explain:

Does this youth have any medical concerns and/or physical limitations (allergies, inhaler, EpiPen, etc.), take any
medication or have medical/behavioral challenges? If so, please explain:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

I hereby give permission for my son/daughter _____________________________________ to participate in the Bona

Buddy Youth Mentoring Program. I understand that I will be contacted regularly to discuss my childs participation in the
program and that I may contact program manager with any questions or concerns.

In addition I give/do not give (please circle) permission to Bona Buddies to take and use my childs photo for the university
website and for program promotional materials.

Parent/Guardian signature: ______________________________________________________ Date:____________