Please indicate how you feel about each statement by placing a "X" in the box that shows how you feel:

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* 1. Please indicate how you feel about each statement by placing a "X" in the box that shows how you feel:

  "Yes" "No"
I get to do my homework during After School Program
After School Program staff help me when I have a question about my homework
I feel safe during the After School Program
I get to play and participate in recreation and physical activities in the After School Program
I enjoy the activity and enrichment classes in the After School Program
If you marked "No" for the statement about Safety (in question 1), please select all the area(s) that you feel are unsafe:

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* 2. If you marked "No" for the statement about Safety (in question 1), please select all the area(s) that you feel are unsafe:

What can we do to make the after school program a safer and better place for you? Please write your ideas below:

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* 3. What can we do to make the after school program a safer and better place for you? Please write your ideas below:

What kinds of enrichment activities would you like in the After School Program? Please write your ideas below:

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* 4. What kinds of enrichment activities would you like in the After School Program? Please write your ideas below:

What kinds of PE activities would you like in the After School Program? Please write your ideas below:

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* 5. What kinds of PE activities would you like in the After School Program? Please write your ideas below:

What is your favorite part of the After School Program?

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* 6. What is your favorite part of the After School Program?

What would you like to see changed in the after school program?

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* 7. What would you like to see changed in the after school program?

Please check the box next to the school you attend:

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* 8. Please check the box next to the school you attend:

Are you a boy or a girl?

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* 9. Are you a boy or a girl?

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