Parent Guardian Questionnaire
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.
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Current school of student (if in school)
Previous Semester/Quarter GPA:
Current Cumulative GPA:
The high school your student is planning on attending next year.
Is your student enrolled in the College Bound program?
Does your student qualify for free or reduced meals?
Did the student's father go to college?
Did the student's father finish college?
Did the student's mother go to college?
Did the student's mother finish college?
Did the student grow up their biological parents?
If 'no', did their guardians go to college?
Did their guardians finish college?
Is there an adult male figure at home?
Please rate your youth's middle school attendance on a scale of 1 to 5. 1 means you did not miss classes. 5 indicates you skipped class on a regular basis.
Please rate your youth's gang involvement on a scale of 1 to 5. 1 indicates you have/had no contact with gangs. 5 indicates you were or are actively involved in a gang on a regular basis.
What are some of your student's interests outside of school?
Has your student exhibited behavior problems in school? If yes, please explain.
Has your student exhibited behavior problems at home? If yes, please explain.
Has your student's had any problems with the law? If yes, please explain.
How many times have you moved in the last five years?
When was the last time you moved and where did you move from?
Do you plan on moving in the next four years? Please explain your answer.
How open do you think your student would be to having a mentor?
Why do you feel your student should be enrolled in the MUST mentoring program?
MUST understands that the following questions are very personal. If you do not feel comfortable answering them then please feel to leave them blank. 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 the child ever experienced one of the following. Please answer the following regarding your student. 1. Has a parent or guardian often or very often… swore at them, insult them, put them down, or humiliate them? or act in a way that made them afraid that they might be physically hurt?
2. Has a parent or other adult in the household often or very often… push, grab, slap, or thrown something at them? or ever hit them so hard that they had marks or were injured?
3. Has a parent or other adult at least 5 years older than them ever… touch or fondle them or have them touch their body in a sexual way? or attempt or actually have sex with them?
4. Did they often or very often feel that … no one in their 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. Have they often or very often felt that … they didn’t have enough to eat, had to wear dirty clothes, and had no one to protect them? or their parents/guardians were too drunk or high to take care of them or take them to the doctor if they needed it?
6. Are their parents separated or divorced?
7. Was their 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. Have they lived 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?
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.
On a sales of 1 - 5, is your Youth reliable? Does he keep is word and tell the truth?
1. He is very reliable, keeps his word and tells the truth.
2. He is often reliable, keeps his word and tells the truth.
3. About half the time he is reliable, keeps his word and tells the truth.
4. Not very often he is reliable, keeps his word and tells the truth.
5. He is not reliable, does not keep his word and does not tell the truth.
On a scale of 1 to 5, how often do you feel like your youth owns the mistakes he makes?
1. He always owns his mistakes
2. He sometimes owns his mistakes
3. About half the time he owns his mistakes
4. He does not own his mistakes very often
5. He rarely owns his mistakes
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.
Is your youth able to think and plan for the future? Does he set goals?
1. He thinks and plans well for the future.
2. He sometimes thinks and plans well for the future.
3. About half the time he thinks and plans well for the future.
4. He does not think and plan very well for the future.
5. He rarely thinks and plans well for the future.
Is he developing the ability to choose right from wrong? Good from bad?
1. He always chooses what is right.
2. He usually chooses right over wrong.
3. About half the time he chooses right over wrong.
4. He chooses wrong more than he chooses right.
5. He rarely chooses the right thing to do.
Does your Youth struggle with his sense of identity?
1. He knows who he is at all times.
2. He sometimes knows who he is.
3. About half the time he knows who he is.
4. He often does not know who he is.
5. He does not know who he is.
How does youth Youth handle negative peer pressure?
1. He is not influenced by negative peer pressure at all.
2. He is sometimes influenced by negative peer pressure at all.
3. About half the time he is impacted by negative peer pressure.
4. He is often impacted by negative peer pressure.
5. He always impacted by negative peer pressure.
Is your Youth on track to graduate high school on time?
Is your Youth on track to graduate high school?
Does your Youth know what career he wants to have?
Thank you for filling out this application! Is there anything else you would like to communicate with us?
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