New Survey

1. Please rate your current knowledge about the Boys and Girls Club Rogers Unit and the youth development programs offered there by checking the most appropriate box

Please rate your current knowledge about the Boys and Girls Club Rogers Unit and the youth development programs offered there by checking the most appropriate box I know nothing about them

I know very little about them

I know something about them

I know a lot about them

2. Please list the school(s) where your children attend

Please list the school(s) where your children attend School 1
School 2
School 3

3. Please check the box by the number of children in your household for each of the following age groups:

	1	2	3	4
Ages 6-8	*Please check the box by the number of children in your household for each of the following age groups: Ages 6-8 1	Ages 6-8 2	Ages 6-8 3	Ages 6-8 4
Ages 12-15	Ages 12-15 1	Ages 12-15 2	Ages 12-15 3	Ages 12-15 4
Ages 9-11	Ages 9-11 1	Ages 9-11 2	Ages 9-11 3	Ages 9-11 4
Ages 16-18	Ages 16-18 1	Ages 16-18 2	Ages 16-18 3	Ages 16-18 4

4. Please tell us where you children stay in the after school and summer hours and check the box by number of children this arrangement applies to. (You may choose more than 1)

	1	2	3	4
Boys and Girls Club	*Please tell us where you children stay in the after school and summer hours and check the box by number of children this arrangement applies to. (You may choose more than 1) Boys and Girls Club 1	Boys and Girls Club 2	Boys and Girls Club 3	Boys and Girls Club 4
Home with Parent	Home with Parent 1	Home with Parent 2	Home with Parent 3	Home with Parent 4
Home with Siblings	Home with Siblings 1	Home with Siblings 2	Home with Siblings 3	Home with Siblings 4
With Other Family	With Other Family 1	With Other Family 2	With Other Family 3	With Other Family 4
Friends	Friends 1	Friends 2	Friends 3	Friends 4
Childcare	Childcare 1	Childcare 2	Childcare 3	Childcare 4
Home Alone	Home Alone 1	Home Alone 2	Home Alone 3	Home Alone 4

Other (please specify)

5. What are the barriers to your children attending the Boys and Girls Club? (Please Check the Boxes for all that apply)

What are the barriers to your children attending the Boys and Girls Club? (Please Check the Boxes for all that apply) Transportation/Location

Inconvenient Hours

Don’t like facility/building

Cost

My Children don’t want to attend

We don’t need the service

Not Applicable - they do attend

Other (please specify)

6. If all of the barriers to attending could be removed, please check the box by the number of children in your household who would attend the Boys and Girls Club?

If all of the barriers to attending could be removed, please check the box by the number of children in your household who would attend the Boys and Girls Club? 1