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WeClimb Child Interest Application
This short application will help us determine if your child is a good fit for the WeClimb Mentoring program. The application will take about 10 minutes to complete and should be completed by a parent with input from their child. PLEASE ANSWER THE QUESTIONS HONESTLY. If you have any additional questions, please add them below or contact us at
weclimbtn@gmail.com
.
If you're enrolling more than one child, please submit a separate application for each child.
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* Indicates required question
Email
*
Your email
Parent/Guardian's Full Name
*
Your answer
Your Child's Full Name
*
Your answer
Phone Number
*
Your answer
Street Address
*
Your answer
City & State (e.g. Chattanooga, TN)
*
Your answer
1.
Describe your child's personality type?
*
Social/Extrovert (prefers being around others)
Solitary/Introvert (prefers being by himself)
Both (depending on the situation)
2. What is your child's top two preferred learning styles? How do they learn best? (Only check 2 boxes.)
*
Auditory (by listening to it)
Visual (by seeing it)
Physical (by doing/touching it)
Verbal (by talking about it)
Logical (by thinking about it)
Other:
Required
3. What is your child's current grade-point-average (GPA)?
*
4.0 - 3.5 (or higher)
3.4 - 3.0
3.3 - 2.5
2.4 - 2.0
1.9 or below
4.
Has your child had any disciplinary problems at school due to behavior (i.e., expulsion, suspensions, detentions, etc.)? If YES: go to Question #5, if NO, go to Question #6.
*
Yes
No
5.
If you answered YES to #4, please provide a short explanation of the type of infraction and why?
Your answer
6.
How would you rate/describe your child's self-esteem (i.e., confidence level)?
*
Choose
Excellent
Good
Fair
Poor
7.
What do YOU think is your child's greatest challenge(s) (check as many that apply)?
*
Physical - (weight, strength, height)
Social - (making friends, peer pressure, girls, bullying)
Emotional - (anger, fear, sadness/hurt, worry/anxiety)
Academic - (grades, studying, testing)
Psychological - (confidence, negative, poor self image)
Other:
Required
8.
Briefly, in one sentence, what do you hope your child will receive by participating in WeClimb (i.e. your desired outcome)?
*
Your answer
9.
Ask your child what they consider to be their greatest ACCOMPLISHMENT they're most proud of?
*
Your answer
10.
Ask your child what they consider to be their greatest CHALLENGE?
*
Your answer
11. How willing/open is your child to participating in a program like this?
*
No interest
1
2
3
4
5
Very interested
12. How willing are you to support your child in WeClimb (i.e. make sure they attend, are on-time, etc.)?
*
Not sure
1
2
3
4
5
Most certainly
13. Does your child have a cell phone so they can receive text messages?
*
Yes
No
If yes, what is their phone number?
Your answer
14. Do you have reliable transportation?
*
Yes
No
15. Does your child have any pre-existing health conditions that could prevent him/her from engaging in strenuous physical activities (i.e., asthma, heart condition, vertigo, fractures, recent surgeries, etc.)?
*
Yes (please specify in the OTHER box below)
No
Other:
Required
16. Re-confirm Your Email Address
*
Your answer
If you have any additional questions, please indicate below. Thank you for allowing us to support you and your child; we take this responsibility very seriously.
Your answer
A copy of your responses will be emailed to the address you provided.
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