This document appears to be a survey for a student to fill out about their community and their experience in a Values Club program. The student is prompted to complete a sentence about their community, provide their name, school, grade, and age. They are then asked a series of yes or no questions about what they learned in their Values Club, how they feel about themselves and others, and if they enjoyed attending the Values Club and would like to attend again.

1. Complete the sentence.
My community is ___________________________.
This is a picture of my community:
Name: _________________________
School: _____________________
Grade: ______ Age: _______
11911 Bammel N. Houston, Suite B2
Houston, TX 77066 – 281.203.0830
www.bridgingfortomorrow.org
Are you a BOY or a GIRL? Circle the correct “face”.

2. This is all about me…
(Tell us YES or NO. Circle your answers. Only circle one answer.)
A snapshot of my
Values Club.
(Check all the options that are true for you.)
At my Values Club I…
o learned how to talk about what I want and
need.
o learned about responsibility, honesty, kindness
and respect
o learned about good manners.
o learned about the community.
Now…
oI care about others.
oI like to share and work in groups.
oI care about myself.
oI can answer these questions.
And…
oI know what to do when someone bullies me.
oI LOVE myself. I think I am “cool”.
oI am happy to be almost done with this survey!
I attended the Values Club last year.
YES NO
I enjoyed spending time at the Values Club.
YES NO
I would like to attend the Values Club next year.
YES NO
I like ice cream.
YES NO