CashBack SHANARRI wheels

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

First Name:

Second Name:

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

first

second

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3. What is your age?

10 or under

11

12

13

14

15

16

17

18

19

20+

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4. What is your gender?

Female

Male

Other (happy to say)

Prefer not to say

You are welcome to specify:

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5. What is today's date?

The date today is:

Date

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

Please explain:

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

Please explain:

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

Please explain: