Age:
Phone: *
Email Address *
Current School: *
Grade: *
What job/career do you envision yourself in when you finish college? *
Question 1: Why do you want to be a part of the YWLA Program? *
Question 2: What does a leader look like to you? Name one person who you consider to be a great leader. *
Question 3: What about your school do you like? What do you find challenging? *
Question 4: Tell us something that you’ve done that you are proud of. *
Question 5: What social issue(s) if any, have you struggled with? For example, bully, low self esteem, peer pressure, etc. *
Question 6: Do you have any special skills, talents, interest or hobbies? For example, arts, dance, music, etc. *
Parent/Guardian Email: *
Parent/Guardian Phone:
Medical Question 1: Does your daughter have any physical problems or limitations? (Yes or No). If yes, please explain. *
Medical Question 2: Is your daughter currently receiving treatment for any medical condition or other challenges? (Yes or No) If yes, please explain. *
Medical Question 3: Is your daughter currently taking any medication? (Yes or No) If yes, please explain. *
Medical Question 4: Does your daughter have any known allergies or adverse reactions to medications (Yes or No). If yes, please explain. *
If you answered "No" to the above question, do you need assistance with obtaining access to computer equipment and reliable internet service? *
Other: