2012 Youth Service Center Assessment-Parents

 
1. Student(s) Live with. . .
Both parents..
Mother..
Father..
Grandparent..
Other (please specify)
2. Number in household...
3. Number of children in household..
4. Please check if applies:
5. Please list the number of children you have in each school.
CCMS
CCHS
Alternative School
6. Please check all items that have affected your child(ren) or family within the last six months...
7. Name the top 3 concerns you have about your child...
8. In your own words, identify the 3 most urgent needs in your family...
9. Please list any additional comments you have about the services/programs that Youth Services Center currently offers.
10. You do not have to put your name on this survey; however, if you would like more information on any of the areas mentioned, we will need your name, address, and phone number to contact or provide you with information.
THANK YOU FOR YOUR TIME!!
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