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. My Gender

* 5. My Age

* 6. Number of Years Being Mentored:

* 7. I am matched to:

* 8. About Me - Please choose the answer to each question that best describes how you feel.

  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 that it is okay to be different
I tell the truth even when it’s hard
Other kids bully me or pick on me at school or in my neighbourhood
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 or community group outside of school
My parent/guardian accepts me the way I am

* 9. 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.

* 10. 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?

* 11. 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?

* 12. About My Mentor
These questions ask about the qualities of our mentor and your relationship with your mentor. Please choose the answer to each question that best describes how you feel or what you believe to be true.

  Strongly Agree Agree Disagree Strongly Disagree
My mentor helps me challenge myself to succeed
I am able to look to my mentor for guidance
My mentor praises me and encourages me to do well
My mentor talks to me about healthy choices
I am proud to tell my mentor when I have done well at some activity
My mentor helps me to see different ways I can deal with problems or new situations
My mentor asks about things that matter to me
I like just talking with my mentor
I feel safe with my mentor
I discuss things I would like to do in my future with my mentor
When I do something that makes me feel bad, I discuss it with my mentor
My mentor helps me to feel good about myself
I feel special when I spend time with my mentor

* 13. On average, how many hours per visit do you spend with your Big/Mentor?

* 14. What were the big things that you learned from your Mentor?

* 15. Did you change at all because you had a mentor? How?

* 16. If possible, I would like to continue meeting with my Mentor.

* 17. I know who my Match Facilitator is

* 18. I feel I can talk to my Match Facilitator

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