Child/Youth Application

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Page 1

(To be completed by WWS staff and parent/guardian of potential mentee between the ages of 7-17 years old)



























Emergency Contact


Please list all members of your household

























Page 2

Mentee Interest Survey (To Be Completed by Youth and Parent)









Page 3

Application Questions
Please answer all of the following questions as completely as possible. If more space is needed, use an extra sheet of paper or write on the back of this page.






5. Please select the number that accurately describes your child's current level in each area. 
 Poor Below Average Average Above Average Outstanding

 Poor Below Average Average Above Average Outstanding

 Poor Below Average Average Above Average Outstanding

 Poor Below Average Average Above Average Outstanding



Page 4

Medical History