Full name Date of birth
Female Male
How would you describe your racial/ethnic group?
American Indian Asian or Pacific, including Hmong, Laotian, Vietnamese Black or African American Caucasian Hispanic, Latino, or Latina Combination of racial groups
What is your current grade level in school?
9th 10th 11th 12th
Mostly A's About half A's and half B's Mostly B's About half B's and half C's Mostly C's About half C's and half D's Mostly D's Mostly below D's
1 Very dissatisfied with how my life is going 2 3 4 5 Slightly dissatisfied 6 Slightly satisfied 7 8 9 10 Very satisfied with how my life is going
Attend clubs, sports, or other organized activities, outside of school class time Volunteer work, without pay, to help your community or church Work for pay
Work for pay
Very true Sort of True Not Very True Not True at all Don't know When some kids that I know are not getting along, I help them work out their differences I am good at helping others to solve their problems I think of myself as a leader among other kids like me I understand some of the challenges faced by a person of color in my community I speak up for people of other races or cultures if I feel they are being treated unfairly I think its important to have friends of different racial or ethnic groups
Very True Sort of True Not Very True Not at all True Don't Know On the whole, I like myself There are many things that interest me in my life My life has a purpose I feel good about what my future holds I can tell that I am on the way to becoming a successful adult When I work toward something, I can make a positive difference in the world Most times, I feel useful and important I have the ability to make my life better I have much to be proud of
Very true Sort of True Not Very True Not True at all Don't know I am usually comfortable speaking in front of a group I have the ability to get other kids organized on a project I am good at persuading others to do something I think should be done I often find myself rushing at the last minute to meet my responsibilities
Very Important Important Not Important Organize others to improve something in my school or community Give my time or money to help make others' lives better Make sure people are treated fairly Stand up for what I believe, even when it's unpopular Tell the truth, even if it means I might look bad or get in trouble Learn about or meet government leaders in my community Understand how my local government works Learn about multicultural issues in my area Understand important issues in my community
Definitely think that about me Think that about me sometimes Don't think that about me at all Don't know Know how to make good choices when someone encourages you to do something you know is dangerous or wrong Are able to plan ahead well Stay away from others who may influence you to do things that are wrong or dangerous Are good at making or keeping friends Work it through when the going gets difficult
Very True Sort of True Not Very True Not at all True Don't Know Adults that I am around really listen to what I have to say I have lots of ways to help make my community a better place In my community there are many chances for me to get involved in things I am interested in The adults that I am around make me feel like I am a good person I could talk to several different adults for advice if I had a serious problem Adults that I am around care about people my age
Very likely you could Somewhat likely Somewhat unlikely Very unlikely you could Don't know Give the name of the current County Executive Give the names of the elected leaders in your community Explain the current situation involving the downtown Mall Explain the current situation involving the river cleanup Explain the current situation involving a water pipeline Explain the current situation involving the County Mental Health Center Explain the current situation involving the County's financial situation Describe the largest industries in the County Describe the history of the County
