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  5. Development Program Survey
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Name
   
 
 
 
What is your age?
 
12
 
13
 
14
 
15
 
16
 
17
 
18 or older
 
 
 
Parent or Guardian name and phone number:
   
 
 
 
What is the highest grade level that you have completed?
 
6th
 
7th
 
8th
 
9th
 
10th
 
11th
 
12th
 
 
 
Math teachers name:
   
 
 
 
Science teachers name:
   
 
 
 
English teachers name:
   
 
 
 
Mentors name and phone number:
   
 
 
 
Please select all that you feel apply to yourself:
 
I do not hear my teachers very well.
 
I do not see the blackboard very well.
 
It is difficult to concentrate.
 
I get bored very easily.
 
I have trouble learning.
 
I am a good student.
 
I have trouble reading.
 
I do not have many opportunities.
 
I do not like to do homework.
 
My temper gets me in trouble.
 
My family does not have much money.
 
My home life is not good.
 
My family does not always have a car.
 
My family does not always have a phone.
 
My father does not live with me.
 
My mother does not live with me.
 
Alcohol causes problems in my family.
 
One of my parents is or has been in prison.
 
Hitting can be a problem in my house.
 
Drugs cause problems in my family.
 
There is a lot of anger in my family.
 
Wrong touching has been a problem in my family.

 
 
 
Height:
   
 
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