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* 1. Please write your birth date in the space below:

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* 2. I am going into:

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* 3. I am:

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* 4. My grades are: and I live in:

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* 5. During the school year, I work:

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* 6. How many school and community organizations have you been involved with in the past year? And how many hours do you spend with them?

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* 7. How do your school and community organizations affect your life in the following areas?

  Positively  Negatively 
Academics
Personal Life
Social Life
Health
Self-Esteem

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* 8. After high school, I want to:

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* 9. Rank the following

  Strongly agree agree neutral disagree strongly disagree
Involvement in student organizations can play an important role in having a good high school education and experience
Serving others is a responsibility of leadership
Understanding my community is an important part of leadership
I can identify inequalities that exist in my community
I believe I have a voice in the decisions of my community
I know how to make a positive change in my community
I have an ethical responsibility to make changes in my community
I know how to work with the people I am serving to make sure both our needs are met
It is important to avoid conflicts in a group
I set clear goals that I want to accomplish in a group
I know how to help groups I work with work as a team
I know how to communicate effectively with members of my group
I believe my group should have 1 leader
I am comfortable supporting others
I am comfortable collaborating with adults
I am comfortable working with people from different backgrounds
I am comfortable giving feedback in a positive way

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* 10. Rate

  I know how to do this and am very comfortable doing so I know how to do this and am comfortable doing so No opinion I know how to do this but I am not comfortable doing this I do not know how to do this right now
I can describe my leadership style
I can identify my personal values
I can explain how my personal values relate to my leadership style
I can seek out leadership training opportunities to help myself grow as a leader
I can explain how or when I decide to stick with my values
I can identify my comfort levels
I can accept my mistakes
I can ask for help when I need it
I accept feedback on my abilities and actions from other members in my group
I accept feedback on my opinions and beliefs from other members in my group

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