Boys & Girls Clubs Big Brothers Big Sisters of Edmonton & Area

Thank you for participating in one of our mentoring programs. Your experience and input is very valuable to us. Please answer all of the questions as honestly as you can and know that there are no right or wrong answers.

* 1. First Name

* 2. Last Name

* 3. Date Survey Completed

* 4. Gender

* 5. Age

* 6. Grade

* 7. About Me. These questions ask how you feel about yourself and other kids.

  Never Sometimes Usually All of the time
I have good ideas
I am good at a lot of things
I share my ideas and feelings with others
New situations are often hard for me to deal with
I get angry easily
I know it is okay to be different
Other kids bully me or pick on me at school or in my neighbourhood
I tell the truth even when it’s hard
I care about other people’s feelings
I like to help others
I get along well with other kids my own age
I can trust my friends with my secrets
I tell my friends “no” if they want to do something bad
I am involved in a sport team or community group outside of school
My parent/guardian accepts me the way I am

* 8. About My School

  Never Sometimes Usually All the time
I enjoy being at school
I feel successful at school
Doing well in school is important for my future
I have trouble figuring out the answers in school
I care what my teachers think about me
I get into trouble at school.
I have trouble completing my homework.
I pay attention in class.

* 9. Think about how you feel when other kids your age do certain things.

  It's not okay It's sort of okay It's mostly okay It's perfectly okay
Using tobacco (cigarettes, cigars, smokeless or chewing tobacco)?
Taking drugs that aren't given to them by a doctor or parent?
Drinking alcohol without their parents knowing?
Skipping school without permission?
Being late for school often or without a reason?

* 10. People in your life

  Yes No
Do you have someone you look up to?
Do you have someone who influences what you do or the choices you make?
Do you have someone you can talk to about personal things?