* 1. Parent Name

* 2. School(s) your child or (children) will attend next year

* 3. Would your child (children) attend an after school program?

* 4. How many days per week would your child attend an after school program?

* 5. Why would you enroll your child (children) in the after school program?

* 6. What programs or support would your child (children) benefit from most?

* 7. Any comments or concerns?

T