Student's Name:

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* 1. Student's Name:

Gender

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* 2. Gender

School

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* 4. School

How many years have you been in the ConnectiKids Program?

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

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

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

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

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

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

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

Do you like yourself?

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* 10. Do you like yourself?

Are you proud of yourself?

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* 11. Are you proud of yourself?

Mark all of the words that describe you:

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

Mark all the goals you have for continuing your education:

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

I will study hard for good grades.

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* 14. I will study hard for good grades.

I understand the importance of attending school.

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* 15. I understand the importance of attending school.

I will work hard to reach my goals.

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

I want to be a positive member of my community.

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

I will have a good job when I grow up.

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

I meet new people at ConnectiKids.

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* 19. I meet new people at ConnectiKids.

I go new places with ConnectiKids.

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* 20. I go new places with ConnectiKids.

I learn new things at ConnectiKids.

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* 21. I learn new things at ConnectiKids.

Fill in the blank: Going to ConnectiKids makes me feel

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

Have you met any positive role models at ConnectiKids?

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

If yes, write their names

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* 24. If yes, write their names

Name three skills or talents you are good at.

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

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

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

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

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

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

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

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

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

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