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. District that you live in:

* 5. Relationship to child:

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

* 7. Gender of your child:

* 8. Youth's Age

* 9. Please rate your child on the following charactieristics as best as you can and as what seems most true to you.

  Never Sometimes Most of the time Always
My child actively participates in their school work.
My child understands that school is 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 follows the rules.
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 feels included by other children.
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.

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