Dear youth, 

    Thank you for taking the time to complete this survey. As I prepare to write a book for your age group I want to know what is foremost in your minds and hearts and tailor the book to your concerns and struggles. Personal information will be kept private and for my use only unless you check the box at the bottom granting me permission to quote your answer or tell your story (changing the name, of course). Thank you again for your help.                              With gratitude, Kiersten Lortz, author and public speaker

Name *
I agree that Kiersten Lortz can use my answers for stories and quotes in publication. I understand that my name and contact information will be kept private. * *
I have parental/guardian permission to complete and submit this survey * *
Kiersten Lortz may contact me to interview me about my answers. * *