CashBack SHANARRI wheels Question Title 1. Please give us your name (or your initials): First Name: Second Name: OK Question Title 2. Is this the first or second time you have filled in this form? first second OK Question Title 3. What is your age? 10 or under 11 12 13 14 15 16 17 18 19 20+ OK Question Title 4. What is your gender? Female Male Other (happy to say) Prefer not to say You are welcome to specify: OK Question Title 5. What is today's date? The date today is: Date OK Question Title 6. What is the name of the youth organisation you attend? OK Question Title 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: OK Question Title 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: OK Question Title 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: OK DONE