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)

Personal Information

Youth's First Name

Youth's Last Name

Street Address

City

State

Postal Code

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Youth

Address

City

State

Postal Code

Parent/Guardian Email

Home Phone

Work Phone

Cell Phone

Youth's Email

Youth's Cell Phone (if applicable)

How did you hear about WWS?

Date of Birth

Gender

Ethnicity

Name of School

Grade

Emergency Contact

Emergency Contact Full Name

Phone Number

Please list all members of your household

First Name

Last Name

Gender

Date of Birth

Relationship to Applicant

First Name

Last Name

Gender

Date of Birth

Relationship to Applicant

First Name

Last Name

Gender

Date of Birth

Relationship to Applicant

First Name

Last Name

Gender

Date of Birth

Relationship to Applicant

First Name

Last Name

Gender

Date of Birth

Relationship to Applicant

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.

Please choose from the following and provide your Annual Household Income. This information is used to help us better understand the population we serve. This information is confidential.

1. Why do you and your child want to participate in a mentoring program?

2. Please describe your family's experience with cancer. Who has been diagnosed with cancer? What type of cancer do or did they have? What are the current circumstances?

3. Briefly describe your expectations for Walk With Sally:

4. Is your child available to meet with a mentor eight hours per month and have contact at least once a week for a minimum of one year? Please explain any particular scheduling issues.

5. Please select the number that accurately describes your child's current level in each area.

Additional Comments:

6. Has your child experienced any traumatic events (i.e. death in the family, abuse, divorce)? If yes, please provide details.

7. Can you provide any additional background information that may be helpful to Walk With Sally in matching your son/daughter with an appropriate mentor?

Page 4

Medical History

Name of Primary Care Physician:

Phone No.:

Does your son/daughter have any physical problems or limitations?

Is your son/daughter currently receiving treatment for any medical issues?

Is he/she currently on any type of medication? If so, please specify.

Does your son/daughter have any known allergies or adverse reactions to medications? If yes, please describe them below.

Does your son/daughter have any emotional issues or problems right now?

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