* 1. What school(s) does your child (ren) attend? (check all that apply)

* 2. Goals for my family include: (check all that apply)

* 3. My child is enrolled in the child care program listed below:

* 4. I am interested in the following program(s) for my child: (check all that apply)

* 5. If enrolled in an After-School program, my child would need care from:

* 6. For the academic portion of the After-School program, please check the areas of curriculum where your child needs assistance: (check all that apply)

* 7. I would be interested in the following enrichment programs offered at the Sierra Madre Community Recreations Center:

* 8. For the enrichment portion of the After-School program, please check the areas that would be of interest to your child: (check all that apply)

* 9. What WEEKLY fee would you be willing to pay for after school care, Monday-Friday, 20 hours per week (4 hrs per day)? What WEEKLY fee would you be willing to pay for winter, spring and summer camps, Monday-Friday, 50 hours per week (10 hours per day)?

* 10. Comments / Suggestions:

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