Wellness Department Survey
Name (Last, First)
What grade are you currently in?
Which class are you currently enrolled in?
If you are enrolled in health, which class period are you in enrolled in?
If you needed help, is there a trusted adult (teacher, counselor, nurse, secretary, custodian, etc.) in the school building that you would feel comfortable approaching?
How likely would you be to approach this adult to share an issue or accomplishment?
There is no adult that I would approach with an issue or accomplishment.
Please indicate by name who this trusted adult is?
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This form was created inside of Regional School Distrct 17.