* 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

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

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

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

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

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

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

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

* 9. Are you a boy or a girl?

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