POE - Parent

Big's Full Name *

Little's Full Name *

Parent's Full Name *

Parent's Email Address *

INSTRUCTIONS: This form is used to report changes you have observed in your child during the last 12 months. The following definitions are offered to clarify the items on this form. Note that these items are somewhat general. You’re encouraged to report on your own specific observations within the general meaning of these definitions. Any questions should be referred to the Match Support Specialist.

We would like you to describe any changes you’ve observed in the below areas over the year. It’s

okay to indicate “don’t know” if you have no knowledge about change in a given area.

GOAL AREA #1: CONFIDENCE 1) Self confidence - A sense of being able to do or accomplish something. 2) Able to express feelings - Is able to reveal, talk about, or discuss feelings. 3) Can make decisions - Thinks before acting and is aware of consequences of behavior. 4) Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc. 5) Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean. 6) Sense of the future - Knows about educational and career opportunities.
CONFIDENCE	No Change	A Little Better	No Change	A Little Worse	Much Worse	Don't Know	Not a Problem
1) Self-confidence
2) Able to express feelings
3) Can make decisions
4) Has interests or hobbies
5) Personal hygiene, appearance
6) Sense of the future
GOAL AREA #2: COMPETENCE 7) Uses community resources - Partakes in service activities, libraries, recreation, church/other faith-based activities. 8) Uses school resources - Uses the library, guidance counselors, tutorial centers. 9) Academic performance - Makes good grades or improves grades. 10) Attitude toward school – Is positive about going to school and abut what can be learned. 11) School preparedness – Completes homework and other assignments. 12) Classroom participation – Actively takes part in learning; responds to questions. 13) Classroom behavior – Pays attention in class; isn’t disruptive. 14) Able to avoid delinquency - Refrains from behaviors that are illegal for person of his or her age. 15) Able to avoid substance abuse - Doesn't use illegal or harmful substances (e.g., drugs, alcohol, tobacco). 16) Able to avoid early parenting - Doesn't engage in sexual behavior likely to result in early parenting.
COMPETENCE	No Change	A Little Better	No Change	A Little Worse	Much Worse	Don't Know	Not a Problem
7) Uses community resources
8) Uses school resources
9) Academic performance
10) Attitude toward school
11) School preparedness (homework)
12) Class participation
13) Classroom behavior
14) Able to avoid delinquency
15) Able to avoid substance abuse
16) Able to avoid early parenting
GOAL AREA #3: CARING 17) Shows trust toward you - Isn't reluctant to confide in you, to accept your suggestions. 18) Respects other cultures - Doesn't stereotype or put down other ethnic, racial, language, or national groups. 19) Relationship with family - Interacts well with other family members. 20) Relationship with peers - Interacts well with persons of own age. 21) Relationship with other adults - Has good interactions with other adults who are not family members.
CARING	No Change	A Little Better	No Change	A Little Worse	Much Worse	Don't Know	Not a Problem
17) Shows trust toward you
18) Respects other cultures
19) Relationship with family
20) Relationship with peers
21) Relationship with other adults

Please update any of the following information for YOU, if it has changed:

Name

Address

City State Zip

Home Area Code & Phone

Employer

Work Area Code/Phone Cell Area Code/Phone

E-Mail

Please update any of the following information for your CHILD, if it has changed:

Name

Address

City State Zip

Home Area Code/Phone Cell Area Code/Phone

School

E-Mail

You must click on SUBMIT
for your responses to be recorded.

Thank You!