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* 1. Name

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* 2. Phone Number

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* 3. Email Address

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* 4. Do you need after school programming for your child(ren) during the Spring semester?

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* 5. Are you willing to pay $340 per month for after-school services?

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* 6. Do you need before school programming for your child(ren) during the Spring semester?

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* 7. Are you willing to pay $120 per month for before-school services?

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* 8. Do you need programming for your child during school breaks such as staff development or student holidays (Christmas, Spring Break, etc.)

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* 9. Are you willing to pay $45 per day for these services?

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* 10. Do you need summer programming for your child(ren)?

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* 11. Are you willing to pay $200 per week for these services?

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* 12. I would be willing to pay additional fees if my child could participate in the following enrichment programs provided during our after school hours:

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* 13. How many children would you anticipate enrolling in the program this school year?

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* 14. How many children would you anticipate enrolling in the program this summer?

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* 15. How many children would you anticipate enrolling in the program for next school year?

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* 16. Additional Comments

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