Extraordinary Child Survey

Thank you for your willingness to complete this survey for Extraordinary Child, Inc. We are asking parents, guardians and other caregivers of children with special needs to help us shape an indoor/outdoor recreational facility that will be located in northern RI. The space will be designed by occupational and physical therapists to accommodate children who face difficulties in typical play areas. The purpose of this survey is to provide the Board and staff of Extraordinary Child with input from caregivers on their likely use of such a facility and to help the leadership of Extraordinary Child to make sound decisions.

1. The mission of Extraordinary Child is to provide a supportive and nurturing environment for children with and without disabilities and their families to engage in safe, fun, therapeutic, and social interaction. How do you judge the importance of this effort?

The mission of Extraordinary Child is to provide a supportive and nurturing environment for children with and without disabilities and their families to engage in safe, fun, therapeutic, and social interaction. How do you judge the importance of this effort? Critical

Very important

Important

Nice to have

Not important

2. The planned facility will offer activities which engage all the senses, including an indoor tree house, slides, swings, ball pits, interactive audio, visual and tactile toys. There will be a seperate room designed to help children relax with soothing sensory experiences. The facility will also provide opportunities for families to play and bond in ways that might not otherwise be available to them. Families may also use the facility to implement sensory diets recommended by school or other therapy providers. (To see the planned facility see our website at www.extraordinarychild.org.) Considering the child or children in your care, how helpful would access to such a facility be?

The planned facility will offer activities which engage all the senses, including an indoor tree house, slides, swings, ball pits, interactive audio, visual and tactile toys. There will be a seperate room designed to help children relax with soothing sensory experiences. The facility will also provide opportunities for families to play and bond in ways that might not otherwise be available to them. Families may also use the facility to implement sensory diets recommended by school or other therapy providers. (To see the planned facility see our website at www.extraordinarychild.org.) Considering the child or children in your care, how helpful would access to such a facility be? Very helpful

Helpful

Not particularly helpful

Not helpful at all

3. How likely is it that you would try out the use of this facility?

How likely is it that you would try out the use of this facility? Would undoubtedly try it out

Very likely to try it out

Likely to try it out

Unlikely to try it out

Would not try it out

4. If you found the use of the facility to be a valuable experience, how often might you use the facility?

If you found the use of the facility to be a valuable experience, how often might you use the facility? Daily

6 times per week

5 times per week

4 times per week

3 times per week

2 times per week

1 time per week

3 times per month

2 times per month

1 time per month

Use would be occasional

Would not use it

5. If your child as an HBTS, PASS or other support worker, how likely would it be that you would encourage that individual to take your child to this facility as an activity?

If your child as an HBTS, PASS or other support worker, how likely would it be that you would encourage that individual to take your child to this facility as an activity? Very likely

Likely

Unlikely

Very unlikely

6. How many children with special needs live in your household?

How many children with special needs live in your household?

7. Considering the child or children you care for, please indicate the relevant diagnoses below (please check all that apply).

Considering the child or children you care for, please indicate the relevant diagnoses below (please check all that apply). Autism spectrum disorders (autism, aspergers’, PDD, PDD-NOS, Retts)

Attention Deficit Hyperactivity Disorder/ADD

Exposure to drugs and alchohol in utero

Traumatic brain injury or other insults to neurology

Global Developmental Delay

Fragile X

Down’s Syndrome

Conditions associated with premature birth

Sensory integration dysfunction

Emotional regulation needs stemming from trauma, bi-polar disorder, anxiety or depression

Physical limitations which inhibit play such as Cerebral Palsy, Muscular Dystrophy, Spina Bifida, cystic fibrosis or other physical disabilities

Social or learning impairments that inhibit meaningful play

Other

8. What is the age of the child (or children) with special needs?

What is the age of the child (or children) with special needs?

9. Are there other children in your care who do not have disabilities? If so, please indicate their ages below.

Are there other children in your care who do not have disabilities? If so, please indicate their ages below.

10. Extraordinary Child is a nonprofit and expects to support the facility, in part, through fundraising activities and grants in order to reduce the cost to caregivers. However, we know that we will be unable to offer use of the facility for free. What would you be willing to pay to use this facility per visit? Payment per visit would include admission for adults and children from the same family.

Extraordinary Child is a nonprofit and expects to support the facility, in part, through fundraising activities and grants in order to reduce the cost to caregivers. However, we know that we will be unable to offer use of the facility for free. What would you be willing to pay to use this facility per visit? Payment per visit would include admission for adults and children from the same family. $5 per visit

$10 per visit

$15 per visit

11. Extraordinary Child is also considering monthly passes that would allow a family to visit as often as they liked. Monthly passes would admit adults and children from the same family. What would you be willing to pay for a monthly pass?

Extraordinary Child is also considering monthly passes that would allow a family to visit as often as they liked. Monthly passes would admit adults and children from the same family. What would you be willing to pay for a monthly pass? $30 for unlimited visits for a month

$40 for unlimited visits for a month

$50 for unlimited visits for a month

$60 for unlimited visits for a month

no interest in monthly passes

12. Extraordinary Child is also considering annual memberships that would allow a family to visit as often as they liked and may include other benefits such as discounts. What would you be willing to pay for an annual membership?

Extraordinary Child is also considering annual memberships that would allow a family to visit as often as they liked and may include other benefits such as discounts. What would you be willing to pay for an annual membership? $300 annual membership

$400 annual membership

$500 annual membership

$600 annual membership

no interest in annual membership

13. How likely is it that you would choose one of the following fee structures?

	Very likely	Likely	Not likely
Pay per visit	*How likely is it that you would choose one of the following fee structures? Pay per visit Very likely	Pay per visit Likely	Pay per visit Not likely
Monthly pass	Monthly pass Very likely	Monthly pass Likely	Monthly pass Not likely
Annual membership	Annual membership Very likely	Annual membership Likely	Annual membership Not likely

14. What is your zip code?

What is your zip code?

15. What is your annual household income?

What is your annual household income? Less than $20,000

$21,000 to $40,000

$41,000 to $60,000

$61,000 to $80,000

more than $81,000

Would prefer not to provide this information

16. If you would like to volunteer or donate to help Extraordinary Child build this facility, please enter your name and contact information below.

If you would like to volunteer or donate to help Extraordinary Child build this facility, please enter your name and contact information below. Name:
Email Address:
Phone Number:

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