PYW W.I.N.G.S. Mentor Program Survey

PYW W.I.N.G.S. Mentor Program Survey
Your Name
Today's Date

MonthDayYear
Date
Birth Date

MonthDayYear
Date
Age
Grade Level
This survey will help us learn about you and the other youth who are participating in the mentoring program. It is important that you answer each question as honestly as you can. Only the program coordinator will see how you answer the questions and he or she will keep your answers confidential.
SECTION 1
Please CHECK ONLY ONE BOX per item.

How many adults in your life parents, teachers, counselors, relatives, friends, etc do the following things for you?

Rows	None	One	2–3	4–5	6 or more
Offer help with schoolwork?
Say something nice when you do something good?
Pay attention to what’s going on in your life?
Correct you when you make a mistake?

How often are the following true for you?

Rows	Never	Sometimes	Often	Very Often
I pay attention in class.
I often come to class prepared.
I work very hard on my schoolwork.

How important is each of the following to you in your life?

Rows	Not At All	Somewhat Important	Important	Very Important
Doing the best I can in school
Doing what I believe is right, even if my friends make fun of me.
Telling the truth, even when it’s not easy.

How important is each of the following to you in your life?

Rows	Not At All	Somewhat Important	Important	Very Important
Accepting responsibility for my actions
Doing my best even when I have to do a job I don’t like.
Volunteering

When you’re faced with a problem or difficult situation, how likely are you to do the following?

Rows	Not At All Likely	Not Very Likely	Somewhat Likely	Very Likely
Go over in my mind what I will say or do.
Talk to someone about how I’m feeling.
Make a plan of action and follow it.

SECTION II: Answer each of the following
What hobbies/interest do you have?
State your favorite TV show and explain why you like it.
What is your favorite subject(s) in school? Please explain why!
What school subject do you like least? Please explain why!
What are possible roadblocks/challenges to your academic success?
If you had to describe yourself, what would you say?
How would your friends or family describe you?
What talents (things that are easy for you to do) do you have?
If you could learn something new, what would it be?
What do you like to do on the weekends?
What do you want to see happen at the program meetings regarding activities:
What types of things would you like to do with your mentor?
What skills (things you’ve learned to do) do you have?
Identify a goal(s) you want to work on with your mentor?
Describe your ideal mentor.
How do you prefer to communicate with your mentor (text, phone, zoom, etc)
Do you have any questions about the program?
SECTION III: Check all that apply to your interest(s)
WalkingCookingCraftsBikingRunningEatingLibraryPhotographyHikingDrawingGardeningMoviesMusicPlaying sportsFishingMuseumsCard games/Board gamesCampingSwimmingAnimalsShoppingIce SkatingWatching sportsBoatingScienceMiniature GolfOther
THANK YOU VERY MUCH FOR COMPLETING THIS SURVEY
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