Youth Promoting Peace Program Survey

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* 1. Please tell us about yourself (youth)

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. I am interested in:

The session beginning March 3, 2023 (14-17 year old males only) - APPLICATIONS DUE BY FRIDAY, FEBRUARY 17TH!

Future sessions (April - December 2023)

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* 3. Parent/Guardian/Caregiver #1 Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Parent/Guardian/Caregiver #2 Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Race

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

White or European American

Biracial

Multiracial

Prefer not to say

Other (please specify)

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* 6. What is your gender identity?

Male

Female

Non-binary

Transgender

Prefer not to say

Other (please specify)

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* 7. What are your preferred pronouns?

She/her/hers

He/him/his

They/them/theirs

Prefer not to say

Other (please specify)

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* 8. What is the name of your school?

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* 9. What grade are you in?

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* 10. Please rate how safe you feel at school.

Very unsafe

Somewhat unsafe

Very safe

Somewhat safe

Neither safe nor unsafe

I don't know

I prefer not to say

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* 11. Please rate how safe you feel in your neighborhood.

Very unsafe

Somewhat unsafe

Very safe

Somewhat safe

Neither safe nor unsafe

I don't know

I prefer not to say

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* 12. Please rate how safe you feel in the home you live in.

Very unsafe

Somewhat unsafe

Very safe

Somewhat safe

Neither unsafe or safe

I don't know

I prefer not to say

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* 13. How often have/do you witness violence?

Never

1-2 times per year

3 or more times per year

1-2 times per month

3 or more times per month

1-2 times per week

3 or more times per week

1-2 times per day

3 or more times per day

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* 14. What activities do you participate in after school and/or on the weekends?

Sports league

Boy Scouts

Girl Scouts

Music

Dance

Writing

Homework help/tutoring

Other

I'd prefer not to say

I don't participate in any activities

Other (please specify)

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* 15. I will need transportation to the program

Yes - one way to Northern

Yes - one way from Northern to my home

Yes - both to Northern and from Northern to my home

I will not need transportation

Youth Promoting Peace Program

1. Application

Question Title

* 1. Please tell us about yourself (youth)

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* 2. I am interested in:

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* 3. Parent/Guardian/Caregiver #1 Information

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* 4. Parent/Guardian/Caregiver #2 Information

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* 5. Race

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* 6. What is your gender identity?

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* 7. What are your preferred pronouns?

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* 8. What is the name of your school?

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* 9. What grade are you in?

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* 10. Please rate how safe you feel at school.

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* 11. Please rate how safe you feel in your neighborhood.

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* 12. Please rate how safe you feel in the home you live in.

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* 13. How often have/do you witness violence?

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* 14. What activities do you participate in after school and/or on the weekends?

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* 15. I will need transportation to the program

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* 16. Do you have any dietary allergies or restrictions? If yes, please list.