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This is only a SAMPLE of what the real survey will look like. Please do NOT distribute this version of the survey to constituents of your program.

If you are interested in using the Vermont Mentoring Surveys for your program, please email benji@mobiusmentors.org to receive your unique survey links.

[Program Name/Info Here]

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* Mentee ID Number:

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* My child is able to make and keep friends easily.

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* When my child disagrees with his/her friends, they are able to work it out.

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* My child is helpful.

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* My child tends to bounce back quickly after hard times.

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* When something is bothering my child, he/she talks to me about it.

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* My child is hopeful about his/her future.

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* My child believes what he/she does now will not affect their future.

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* My child likes going to school.

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* My child cares about how he/she does in school.

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* I feel like my child matters to people in our community.

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* My child has another adult, outside of his/her family, whom he/she turns to for support.

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* I will notice positive changes in my child during the time he/she has a mentor.

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* Which best describes your role in your child’s education? (check all that apply)

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* In the last four weeks, how many days was your child absent from school?

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* How far would you LIKE your child to go in school?

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* How far do you THINK your child will go in school?

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