Family Education Program Survey

1. I am interested in participating in classes or workshops about:

I am interested in participating in classes or workshops about: Parenting Issues and Concerns

Child Development

Parent and Child Together Activities, Outings, and/or Field Trips

Personal Wellness, Health, and Safety

Helping My Child Succeed in School

Adult Education (GED or Post Secondary)

Resume Writing and/or Job Search Assistance

Computer Operations (email, file/photo sharing, MS Office, etc)

Social Networking (Facebook, MySpace, Plaxo, etc)

Advanced Computer Operations (online banking/bill paying, internet shopping, etc)

Internet Safety (identity theft, online predators, cyber bullying)

Other (please specify)

2. My educational needs include:

My educational needs include: GED (Lack of High School Diploma)

Writing and Communication

Math Refresher

Job Training (Civil Service, College Board, or Other Test Prep)

Typing/Keyboarding Practice

Basic Computer Skills (Email, File/Photo Sharing, Microsoft Office, etc)

Advanced Computer Skills (Website Building, PowerPoint, Social Networking, etc)

Other (please specify)

3. I am most likely to be able to attend classes/activities in the:

I am most likely to be able to attend classes/activities in the: Morning (between 8:00 am and 11:00am)

Afternoon (between 1:00 pm and 4:00 pm)

Either Morning or Afternoon

Not Sure

4. I would most likely be available on these days of the week (check all that apply):

I would most likely be available on these days of the week (check all that apply): Monday

Tuesday

Wednesday

Thursday

Friday

5. Would you be interested in evening classes/workshops?

Would you be interested in evening classes/workshops? Yes

No

Maybe

6. Please check the reasons that might prevent you from attending classes/activities:

Please check the reasons that might prevent you from attending classes/activities: No Transportation

Lack of Reliable Child Care

Daytime or Unpredictable Work Schedule

It's Hard for Me to Get Motivated

I'm Not Sure I Could Pass the GED

Other (please specify)

*
7. Please complete the following:

Please complete the following: Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

8. Tell us about who lives in your home.

	Males	Females
Adults	Tell us about who lives in your home. Adults Males	Females
Children	Children Males	Females

9. I have a child/grandchild (or care for a child) between the ages of infancy through age 8 (or Grade 3)?

I have a child/grandchild (or care for a child) between the ages of infancy through age 8 (or Grade 3)? Yes

No

10. After you are satisfied with your answers, please enter today's date and submit the form. You will be contacted shortly.

	Month	Day	Year
Today's date is:	After you are satisfied with your answers, please enter today's date and submit the form. You will be contacted shortly. Today's date is: Month	Day	Year

Family Education Program
Exit this survey

1. Default Section

1. I am interested in participating in classes or workshops about:

2. My educational needs include:

3. I am most likely to be able to attend classes/activities in the:

4. I would most likely be available on these days of the week (check all that apply):

5. Would you be interested in evening classes/workshops?

6. Please check the reasons that might prevent you from attending classes/activities:

*
7. Please complete the following:

8. Tell us about who lives in your home.

9. I have a child/grandchild (or care for a child) between the ages of infancy through age 8 (or Grade 3)?

10. After you are satisfied with your answers, please enter today's date and submit the form. You will be contacted shortly.

Family Education ProgramExit this survey

1. Default Section

1. I am interested in participating in classes or workshops about:

2. My educational needs include:

3. I am most likely to be able to attend classes/activities in the:

4. I would most likely be available on these days of the week (check all that apply):

5. Would you be interested in evening classes/workshops?

6. Please check the reasons that might prevent you from attending classes/activities:

*7. Please complete the following:

8. Tell us about who lives in your home.

9. I have a child/grandchild (or care for a child) between the ages of infancy through age 8 (or Grade 3)?

10. After you are satisfied with your answers, please enter today's date and submit the form. You will be contacted shortly.

Family Education Program
Exit this survey

*
7. Please complete the following: