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4-H Chaperone Training Evaluation (PRE)

 

1. Please complete the following information:

Please complete the following information:   Name:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP:
County:
Email Address:
Phone Number:

2. Are you a registered volunteer leader with 4-H?

Are you a registered volunteer leader with 4-H?   Yes No Application submitted

3. Gender

Gender   Female Male

4. Ethnicity

Ethnicity   Hispanic or Latino Not Hispanic or Latino

5. Race

Race   American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

6. My skills for involving young people as partners in planning and decision making during an event.

My skills for involving young people as partners in planning and decision making during an event.   Excellent Good Low None

7. My confidence to delegate tasks or roles to youth.

My confidence to delegate tasks or roles to youth.   Excellent Good Low None

8. My ability to work with youth who are different from me.

My ability to work with youth who are different from me.   Excellent Good Low None

9. My understanding of how to use positive intervention techniques with youth.

My understanding of how to use positive intervention techniques with youth.   Excellent Good Low None

10. My confidence to help youth develop friendships and self-confidence in new situations.

My confidence to help youth develop friendships and self-confidence in new situations.   Excellent Good Low None

11. My understanding of my role and responsibilities as a chaperone.

My understanding of my role and responsibilities as a chaperone.   Excellent Good Low None

12. My understanding of ways to establish a safe environment for youth during an event.

My understanding of ways to establish a safe environment for youth during an event.   Excellent Good Low None

13. My awareness of the steps to report child maltreatment.

My awareness of the steps to report child maltreatment.   Excellent Good Low None

14. My knowledge of preparing for events and activities to minimize risks.

My knowledge of preparing for events and activities to minimize risks.   Excellent Good Low None

15. My understanding of appropriate dress for 4-H events and activities.

My understanding of appropriate dress for 4-H events and activities.   Excellent Good Low None

16. My knowledge of what to do with youth incase of an emergency (medical, security, weather) at an event.

My knowledge of what to do with youth incase of an emergency (medical, security, weather) at an event.   Excellent Good Low None