Name:_____________________________________________ Gender: Male / Female

Grade in school: ____________ School: _____________________________________

Ethnic Background: (Please select one or more):

____ American Indian or Alaska Native ____ Asian ____ Black or African American
____Native Hawaiian or Pacific Islander ____Caucasian ____Hispanic/Latino

1. Do you have a profile on Facebook or Myspace?

____ Both ____ Only Facebook ____ Only Myspace

2. Do you watch YouTube or TeacherTube?

____ Both ____ Only YouTube ____ Only TeacherTube

3. What are your favorite sites to go to online (List as many as you’d like)?

____________________________________________________________________________

4. What do you like do after school for fun?

____________________________________________________________________________

5. What are your favorite radio stations to listen to?

____________________________________________________________________________

6. What kind of music do you like?

____________________________________________________________________________

7. Do you play any sports? If yes, which ones?

____________________________________________________________________________

8. What electronic devices do you have? Check all that apply.

____ iPod ____Cell Phone ____Laptop ____Portable video game player

____Other, please list:__________________________________________________________

9. Do you have a personal saving account (not your parents)?

____Yes ____No ____I’m not sure

10. Do you have a job or an allowance?

____Both ____ I have a job ____ I have an allowance

11. What do you want to be when you grow up?

____________________________________________________________________________

12. Do you want to go to college?

____ Yes ____ No ____Haven’t decided

If you answered yes to #12,

Where do you want to go?

I want to go to:______________________________________ I don’t know__________

Have you talked with your parents about college?

____Yes ____No, but I will ____ No, and I won’t

Do you know how it’s going to be paid for? Check all that apply:

____ My parents will pay for all of it ____ My parents will help me pay
____ I will pay for all of it ____ I hope to get financial aid/scholarships/loans ____I don’t know

If you answered no to #12,

What is keeping you from going to college?

____________________________________________________________________________

13. Did your parents go to college?

____ Yes, both parents ____ Yes, one of my parents ____No, neither ____ I don’t know

14. Who is your role model and why?

____________________________________________________________________________

15. Do you like school?

____________________________________________________________________________

16. What have you heard about college?

____________________________________________________________________________

17. Is college is important to you?

____________________________________________________________________________