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BLACKMAT MMA Background Information How old are you?.............................................................................................................. How old were you when you first joined BlackMat MMA?............................................. How often do you come to BlackMat MMA?  4 to 5 times a week  2 to 3 times a week  Once a week

 A couple times a month  Once a month  Less than once a month Male 

Female 

ASIAN 

MIXED 

RELATIVE 

OTHER 

Are you a……………………………………………………………………………………………..

What ethnicity are you?.......................

Who do you live with?....

MOM 

BLACK  DAD 

HISPANIC 

WHITE 

MOM & DAD 

If you selected Other please explain_________________________________________ What was your average grade in school before you joined BlackMat MMA? …………….. (Write A, B, C, D, or F)

What is your average grade in school now? ………………………………………………………….. (Write A, B, C, D, or F)

Have you ever lived in a foster home or a group home?...................................................

YES NO  

Were you gang-affiliated prior to joining BlackMat MMA?.............................................. Are you gang-affiliated now?.............................................................................................

YES  

NO  

Were you ever in trouble with the law before coming to BlackMat MMA?...................... Have you ever been in trouble with the law since you joined BlackMat MMA?...............

YES  

NO  

Are you currently on probation?........................................................................................

YES 

NO 

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BLACKMAT MMA Questions Coming to BlackMat MMA has helped me to… YES

KIND OF

NOT REALLY

1. Do better in school……………………………………………..

2. Spend more time doing my homework………………….

3. Try harder in school…………………………………………...

4. Get along better with my classmates…………………….

5. Get along better with my teachers………………………..

6. Enjoy sports, exercise, and/or recreational activities more…………………………………………………...

7. Be better at sports and/or recreational activities…………………………………………………………….

8. Feel a stronger connection to my community………..

9. Feel better about myself because I help others………

10. Know more about people of other cultures, races, or ethnic groups……………………………………………………..

11. Care more about young people of other cultures, races, or ethnic groups………………………………………..

12. Have more respect for young people of other cultures, races, or ethnic groups…………………………..

13. Try harder not to judge people based on skin color………………………………………………………………….

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BLACKMAT MMA Coming to BlackMat MMA has helped me to… YES

KIND OF

NOT REALLY

14. Be more aware that I sometimes have ideas about people that are not true……………………………………….

15. Be better at making friends………………………………….

16. Be better at telling others about my ideas and feelings………………………………………………………………

17. Be better at listening to other people…………………….

18. Work better with others on a team……………………….

19. Make better decisions…………………………………………

20. Be better at planning ahead…………………………………

21. Be better at setting goals……………………………………..

22. Be better at solving problems………………………………

23. Be more of a leader……………………………………………..

24. Be better at taking care of problems without violence or fighting……………………………………………..

25. Care more about other people………………………………

26. Be better at standing up for what I believe in…………

27. Tell the truth more often even what it is hard………..

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BLACKMAT MMA Coming to BlackMat MMA has helped me to… YES

KIND OF

NOT REALLY

28. Be better at taking responsibility for my actions…….

29. Be more interested in community and world problems……………………………………………………………

30. Be better at speaking up for people who have been treated unfairly…………………………………………………..

31. Be better at saying “no” to things I know are wrong

32. Stay away from trouble……………………………………….

33. Stay away from tobacco……………………………………….

34. Stay away from alcohol……………………………………….

35. Stay away from drugs………………………………………….

36. Stay away from violence and fighting……………………

37. Feel I have more control over things that happen to me…………………………………………………………………....

38. Feel that I can make more of a difference……………..

39. Feel better about myself……………………………………..

40. Feel better about my future………………………………….

41. Learn that I am better at handling whatever comes my way………………………………………………………………

(If you have not used tobacco, please leave this blank) (If you have not used alcohol, please leave this blank) (If you have not used drugs, please leave this blank)

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BLACKMAT MMA

Please check the box below that is closest to how you feel about the staff at BlackMat MMA YES

KIND OF

NOT REALLY

1. The activities are fun at BlackMat MMA….………….

2. I learn about new things at BlackMat MMA…………

3. I like coming to BlackMat MMA…..……..……………..

4. There are rules I am expected to follow at BlackMat MMA…………..…………………………………………..……..…

5. I feel safe at BlackMat MMA………………………………..

6. Staff care about me…………………………..…………………

7. Staff can be trusted……………………………………………..

8. Staff expects me to try hard to do my best…………….

9. I could go to a staff member at BlackMat MMA for advice if I had a serious problem….………………………

10. Staff treats all kids fairly……………………………………..

Participating in BlackMat MMA has been important to me because…

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BlackMat Survey