Peer Resources Participant Sign Up Fall 2011

Participant Registration

Please read the following before you begin this survey.

This survey asks you to complete questions about your background, schooling, activities you participate in, and the people in your life. The purpose of this survey is to get a better sense of who you are so that your school’s programs can best support you. Everyone in Peer Resources at your school will complete this survey.

You will be asked to complete a similar survey at the end of the year. We ask for your name so that we can match the two surveys.

We are interested in learning about your experiences in this program. Please answer the questions honestly. There are no right or wrong answers. We just want your opinion. If you do not want to answer a question please skip it.

School *

First Name *

Last Name *

Date of Birth Enter as MM/DD/YYYY *

Primary Language

Additional Language Proficiencies

Please specify any additional language proficiencies not listed above

Ethnicity *

If you answered "Multiethnic", which ethnicities do you identify with? Hold 'Ctrl' or 'Apple' to select multiple items

If you selected any of the 'Other' options, which ethnicities do you identify with?

Gender

Grade Level *

How did you find out about Peers?

Participant Pre-Survey Page 1

How True Are These Statements About You?


I am actively engaged in learning new things	Not At All TrueA Little TruePretty Much TrueVery Much True
I am eager to do well in school and other activities	Not At All TrueA Little TruePretty Much TrueVery Much True
I am encouraged to try things that might be good for me	Not At All TrueA Little TruePretty Much TrueVery Much True
I care about school	Not At All TrueA Little TruePretty Much TrueVery Much True
I do my homework	Not At All TrueA Little TruePretty Much TrueVery Much True
I enjoy learning	Not At All TrueA Little TruePretty Much TrueVery Much True
I make important decisions with a lot of care and thoughtfulness.	Not At All TrueA Little TruePretty Much TrueVery Much True
I have goals and plans for the future	Not At All TrueA Little TruePretty Much TrueVery Much True
I plan to go to college or some other school after high school	Not At All TrueA Little TruePretty Much TrueVery Much True
I plan to graduate high school	Not At All TrueA Little TruePretty Much TrueVery Much True
If you are paying attention, please select "Pretty Much True"	Not At All TrueA Little TruePretty Much TrueVery Much True
I have friends about my age who really cares about me	Not At All TrueA Little TruePretty Much TrueVery Much True
I have people about my age who help me when I'm having a hard time	Not At All TrueA Little TruePretty Much TrueVery Much True
I have people about my age who talk with me about my problems	Not At All TrueA Little TruePretty Much TrueVery Much True

Participant Pre-Survey Page 2

How True Are These Statements About You?


I understand my moods and feelings	Not At All TrueA Little TruePretty Much TrueVery Much True
I understand why I do what I do	Not At All TrueA Little TruePretty Much TrueVery Much True
There is a purpose in my life	Not At All TrueA Little TruePretty Much TrueVery Much True
I can do most things if I try	Not At All TrueA Little TruePretty Much TrueVery Much True
There are many things that I do well	Not At All TrueA Little TruePretty Much TrueVery Much True
I avoid things that are dangerous or unhealthy	Not At All TrueA Little TruePretty Much TrueVery Much True
If you are paying attention, please select "Not At All True"	Not At All TrueA Little TruePretty Much TrueVery Much True
I build friendships with other people	Not At All TrueA Little TruePretty Much TrueVery Much True
I express my feelings in proper ways	Not At All TrueA Little TruePretty Much TrueVery Much True
I resist bad influences	Not At All TrueA Little TruePretty Much TrueVery Much True
I make good choices	Not At All TrueA Little TruePretty Much TrueVery Much True
I plan ahead	Not At All TrueA Little TruePretty Much TrueVery Much True
I am on track to graduate high school on time	Not At All TrueA Little TruePretty Much TrueVery Much True
I know the steps necessary to go to college	Not At All TrueA Little TruePretty Much TrueVery Much True

Participant Pre-Survey Page 3

In My Home There is an Adult…


In my home, there is an adult who is interested in my school work	Not At All TrueA Little TruePretty Much TrueVery Much True
In my home, there is an adult who talks with me about my problems	Not At All TrueA Little TruePretty Much TrueVery Much True
If you are paying attention, please select "Very Much True"	Not At All TrueA Little TruePretty Much TrueVery Much True
In my home, there is an adult who listen to me when I have something to say	Not At All TrueA Little TruePretty Much TrueVery Much True
In my home, there is an adult who expects me to follow the rules	Not At All TrueA Little TruePretty Much TrueVery Much True
In my home, there is an adult who believes that I will be a success	Not At All TrueA Little TruePretty Much TrueVery Much True
In my home, there is an adult who always wants me to do my best	Not At All TrueA Little TruePretty Much TrueVery Much True

How True Are These Statements About Your Friends?


My friends get into a lot of trouble	Not At All TrueA Little TruePretty Much TrueVery Much True
My friends do well in school	Not At All TrueA Little TruePretty Much TrueVery Much True
My friends try to do what is right	Not At All TrueA Little TruePretty Much TrueVery Much True