Re-Empowering the Village (REV) - Participant Questionnaire and Application

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* 1. Participant: Give us your contact information (if question does not apply type N/A)

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell Phone Number

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* 2. Participant: Contact Information Continued...(if question does not apply type N/A)

Land Line (if no cell)

Birthdate (MM/DD/YYYY)

Age

Gender (M or F)

Occupation

Grade

School

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* 3. If under age 21: Parent/Guardian Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. What are your preferred contact preferences (check all that apply)

text

cell phone

land phone

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* 5. Why are you interested in participating in the REV Program?

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* 6. What is the #1 thing you want to get out of the REV Program?

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* 7. What is your profession? (example: student, teacher, retiree)

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* 8. What are your greatest strengths? (example: communication skills, people skills, writing skills, honesty, patience, initiative, self-motivation, computer literacy, creative)

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* 9. What are your weaknesses? (example: a particular subject, not taking criticism well, impatient, lazy, procrastinate, not finishing tasks, bullying others)

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* 10. What are your hobbies? (example: visual arts, fishing, electronic games, sports, music, reading, travel, etc)

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* 11. Describe the ideal partner you are looking for in this program.

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* 12. What topics are you passionate about? (examples: social injustice, environmental issues, sports, etc)

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* 13. What areas would you like to develop/grow in?

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* 14. What are some challenges you are experiencing and trying to overcome?

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* 15. How would you describe your personality? (example: quiet, shy, outgoing, extrovert/introvert, sensitive, friendly, adventurous, etc)

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* 16. How would you describe yourself? (example: sports nut, techie, social butterfly, dog lover, foodie, health nut, traveler, etc)

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* 17. To ensure the safety and preferences of all participants in the program, we will be following all of the CDC Protocols as it relates COVID. With that in mind, please select from the list below all that apply to your preferences for interfacing with your selected partner and your participation in our program sessions:

Zoom, virtual communications

Phone

In building - social distance with mask

Outdoor with mask

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* 18. Have you had the COVID Vaccine?

Yes

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* 19. Anything else you would like us to know about you?

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* 20. How did you learn about the REV Program?

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* 21. These two questions are to be answered only by participants under age 25: (If you are over 25, go to end of survey and click "Done")

a. What extra-curricular activities are you involved in?

b. Where do you see yourself in the next 5-10 years?