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.

First Name

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* 1. First Name

Last Name

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* 2. Last Name

Date Survey Completed

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* 3. Date Survey Completed

District that you live in:

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* 4. District that you live in:

Relationship to child:

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* 5. Relationship to child:

Child's Name (First and Last Name)

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* 6. Child's Name (First and Last Name)

Gender of your child:

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* 7. Gender of your child:

Youth's Age

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* 8. Youth's Age

My child is matched to:

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* 9. My child is matched to:

My child has been matched

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* 10. My child has been matched

These questions pertain to your observations of your child and changes that have occurred over the mentoring period. Please rate your child on the following characteristics as best as you can and what seems most true to you.

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* 11. These questions pertain to your observations of your child and changes that have occurred over the mentoring period. Please rate your child on the following characteristics as best as you can and what seems most true to you.

  Never Sometimes Most of the time Always
My child understands that school in important
My child attends school regularly
My child completes homework and other assignments
My child knows the difference between right and wrong
My child thinks before acting and is aware of the consequences of his/her behaviour
My child makes good decisions
My child and I get along well
My child gets along with other family members
My child gets along well with their peers
My child is picked on by other children
My child picks on other children
My child gets along with other adults (teachers, coaches, etc.)
My child has someone in his/her life that he/she can confide in
My child stereotypes or puts down other ethnic, racial, language or national groups
My child can share his/her feelings.
My child has a positive attitude
My child uses their spare time in constructive ways
My child engages in illegal activity (i.e. vandalism, graffiti, stealing, etc.)
My child uses non-prescription drugs or alcohol
How would you rate your child's relationship with their mentor? Has it been a positive or negative experience?

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* 12. How would you rate your child's relationship with their mentor? Has it been a positive or negative experience?

Please provide comments regarding your support and contact with the Match Facilitator throughout the past year.

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* 13. Please provide comments regarding your support and contact with the Match Facilitator throughout the past year.

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