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* 1. What School do you attend?

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* 2. What Grade are you in?

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* 3. What is your gender?

The Following Questions are about the 21st Century after-school program. Please answer all questions honestly. Your answers will help us improve this program. Your name is not on this form.

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* 4. I feel welcomed in this program

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* 5. I like being in this program?

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* 6. I have friends in this program?

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* 7. At least one adult (staff) in this program cares about me?

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* 8. The adults (staff) in this program care about what I have to say?

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* 9. The adults (staff) here expect me to do well in school?

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* 10. The adults (staff) here expect me to attend school each day?

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* 11. The adults (staff) here treat me fairly most of the time?

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* 12. This program helps me with school stuff (like getting my homework done)?

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* 13. When I have a problem there is an adult in this program I can talk to?

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* 14. This program has helped me learn how to get along with others?

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* 15. What we do here will help me in the future?

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* 16. In this program, I have done things that make me feel good about myself?

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* 17. I get to have some say in the program activities we do?

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* 18. What suggestions do you have for improving the 21st century after school program?

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