Parent Guardian Questionnaire

Youth Application

Dear Parent or Guardian, Thank you for taking the time to fill out this questionnaire. The questionnaire is vital to helping us understand your student and their possible placement in the mentoring program. If a student is accepted into the mentoring program a considerable amount of time, resources, and commitment will be put behind them for the next four years in order to assure they graduate from high school and possibly go to college or get established in a stable career. Because of this investment we want to honor our donors and research each potential mentee to the best of our ability. Your responses help us determine how best we can serve you, your student and your family. Ready to go? Great, tell us all about your student! Always feel free to elaborate on your answers in the margins. Be assured that the information you provide below will be kept strictly confidential.
  • Adverse Childhood Experiences (ACE)

    MUST understands that the following questions are very personal. If you do not feel like completing this section then feel total freedom to skip it. The answers to these questions are helpful in matching you, the Coach, to your potential Mentors, but are not necessary. We measured the prevalence of ten Adverse Childhood Experiences (ACE), consisting of whether you, as a child, child ever experienced one of the following. Please answer the following questions regarding your childhood and keep a running tally in your head. At the end, please total the number of times you answer yes to any of these questions.

    1. Did a parent or other adult in the household often or very often… swear at your youth, insult your youth, put them down, or humiliate them, or act in a way that made them afraid that they might be physically hurt?

    2. Did a parent or other adult in the household often or very often… push, grab, slap, or throw something at your youth? or ever hit them so hard that they had marks or were injured?

    3. Did an adult or person at least 5 years older than your youth… touch or fondle them or have them touch their body in a sexual way? or attempt or actually have sex with them?

    4. Did your youth often or very often feel that … no one in your family loved them or thought they were important or special? or their family didn’t look out for each other, feel close to each other, or support each other?

    5. Did your youth often or very often feel that … they didn’t have enough to eat, had to wear dirty clothes, and had no one to protect them? or your parents were too drunk or high to take care of them or take them to the doctor if you needed it?

    6. Were their parents ever separated or divorced?,

    7. Was your youth's mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

    8. Did your youth live with anyone who was a problem drinker or alcoholic, or who used street drugs?

    9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

    10. Did a household member go to prison?

  • Assessment

    MUST assesses its Youth each year in three areas: Becoming a Man, Adolescent Development and Academics. Will you please assess your Youth in each of these areas below?

    Becoming a Man

    MUST teaches its Youth that there are 8 things that make a man. Each year the youth are held accountable for two of the eight. In the first year MUST teaches its Youth that a man 1) Is reliable and keeps his word and 2) A man owns his mistakes.
  • Adolescent Development

    Please assess your Youth on the following three adolescent development stages. It is normal for Youth not to be doing well in some of these areas.
  • Academic/Career Development

    Is your Youth on track to graduate high school on time?