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

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* 1. Please indicate how you feel about each statement by placing an "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 sports 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 place an "X" in the box(es) next to the areas that make you feel unsafe in your After School Program:

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* 2. If you marked "No" for the statement about Safety (in Question 1), please place an "X" in the box(es) next to the areas that make you feel unsafe in your After School Program:

What kind of enrichment would you like in the after school program? Check the ones you would enjoy:

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* 3. What kind of enrichment would you like in the after school program? Check the ones you would enjoy:

What kinds of physical activities would you like in the after school program? Check the ones you would enjoy:

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* 4. What kinds of physical activities would you like in the after school program? Check the ones you would enjoy:

What is your favorite part of after school program?

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* 5. What is your favorite part of after school program?

Check the box next to the school you attend:

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* 6. Check the box next to the school you attend:

Are you a boy or a girl?

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* 7. Are you a boy or a girl?

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