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Consent Form

Consent Form

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* 1. How many school-age children do you have?

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* 2. Please specify your age range? Click the appropriate range below.

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* 3. Please specify your ethnicity.

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* 4. What is your marital status?

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* 5. Employment Status: Are you currently…?

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* 6. What is your total household income?

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* 7. What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.

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* 8. Which region of the country do you live in?

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* 9. What is the age range of your child/children? Click all that apply.

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* 11. What is the grade level range of your child/children? Click all that apply.

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* 12. Does your child have daily chores that are required of him/her?

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* 13. Rate the level of your child/children’s academic stamina/productivity over the summer.

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* 15. Would an in-home summer program be something you would be interested in?

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* 16. If you chose yes to the question above, would you prefer a complete in-home summer program (Entire 8-hour day planned) or a partial summer in-home program (Daily activities)?

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* 17. If you could choose how many hands-on academic activities your child could to do per day, how many are appropriate?

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* 18. How much time per day do you think should be set aside for learning in the summer?

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* 19. During the summer, would you be willing to take field trips once per week or every other week with your children?

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* 20. How much money would you be willing to spend on a complete summer in-home program (Entire 8-hour day planned)?

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* 21. How much money would you be willing to spend on a partial summer in home program (Daily activities)?

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* 22. On average, how many minutes per day does your child read during the school year at home?

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* 23. How many minutes per day does your child read during the summer at home?

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* 24. On average, how many minutes daily does your child spend outside in the summer?

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* 25. What portion of the day are you and/or your partner at home during the summer?

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* 26. During the summer, who is your child’s main caretaker?

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* 27. How often does your child complain of boredom in the summer?

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* 28. Does your child follow a schedule during the school year?

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* 29. Would you find a summer in-home program that could be easily implemented into your home beneficial?

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* 30. Rate the level of difficulty (1 being the least difficult and 5 being the most difficult) in identifying and/or implementing engaging academic related activities that are appropriate for your child during the summer.

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