* 1. Student's Name:

* 2. Gender

* 4. School

* 6. How many years have you been in the ConnectiKids Program?

* 7. Mark all of the things you talk about with any adult at ConnectiKids:

* 8. Mark all of the things that your tutor does for you:

* 9. Mark all of the adults you feel comfortable with when you are at ConnectiKids:

* 10. Do you like yourself?

* 11. Are you proud of yourself?

* 12. Mark all of the words that describe you:

* 13. Mark all the goals you have for continuing your education:

* 14. I will study hard for good grades.

* 15. I understand the importance of attending school.

* 16. I will work hard to reach my goals.

* 17. I want to be a positive member of my community.

* 18. I will have a good job when I grow up.

* 19. I meet new people at ConnectiKids.

* 20. I go new places with ConnectiKids.

* 21. I learn new things at ConnectiKids.

* 22. Fill in the blank: Going to ConnectiKids makes me feel

* 23. Have you met any positive role models at ConnectiKids?

* 24. If yes, write their names

* 25. Name three skills or talents you are good at.

* 26. What skill or talent would you like to get better at?

* 27. Mark all of the things you do when faced with challenges.

* 28. Mark all of the people you feel comfortable going to when faced with peer conflict/issue

* 29. Mark all of the things you feel confident to do when faced with peer pressure.

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