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1. Please give us your name (or your initials):

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2. Is this the first or second time you have filled in this form?

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3. What is your age?

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4. What is your gender?

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5. What is today's date?

The date today is:

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6. What is the name of the youth organisation you attend?

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7. On a scale from 0 (not at all)  to 5 (very) rate the following for how you feel when taking part in this youth activity:

  0 (not at all) 1 2 3 4 5 (very)
Safe 
Healthy
Active
Nurtured
Achieving
Respected
Responsible
Included

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8. On a scale from 0 (not at all) to 5 (very) rate the following for how you feel when at school:

  0 (not at all) 1 2 3 4 5 (very)
Safe
Healthy
Active
Nurtured
Achieving
Respected
Responsible
Included

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9. On a scale from 0 (not at all) to 5 (very) rate the following for how you feel when at home:

  0 (not at all) 1 2 3 4 5 (very)
Safe
Healthy
Active
Nurtured
Achieving
Respected
Responsible
Included

T