Powerhouse Questionaire
1. Have you ever experienced the Powerhouse Assembly program? Yes or NO (Circle one)
2. Do you feel your choices play a large role in affecting your ability to reach your goals in life?
3. Do you feel the Powerhouse assembly program motivated you to make good choices?
4. Explain your response to question #3 ________________________________________________
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5. Tell us your story, how have good choices or bad decisions impacted your life? __________
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Finally, tell us a little about yourself:
Name (optional) __________________________________________________
Age __________ Birthday (MM/DD/YY) __________________ Grade in School _________
School _______________________________________________
Male or Female ___________
Please fax this Questionaire to 615-694-5003 or email to cym@comcast.net
