Please answer each question as honestly as possible. This information will be used to help Dillard Academy apply for grants and to improve our programs for students and parents. No individual data will be released.

* 1. 1. Please list the names and grade levels for your children who attend or have attended DACS
First Name/Grade Level. (i.e. Rebecca/2nd)

* 2. How many people at each age group live in your household?

* 3. Relationship to the Dillard Academy student. (Check all that apply if survey being completed by more than one guardian.)

* 4. The head of your household is:

* 5. (Guardian 1) I am:

* 6. Guardian 2, if applicable: I am:

* 7. Highest grade completed:
(Guardian 1)

* 8. Highest Grade Completed:
(Guardian 2)

* 9. Is anyone in the household currently in college?

* 10. What is the ANNUAL income of your household?

* 11. What type of home do you and your family live in?

* 12. Has anyone in your family been in jail, juvenile court or prison in the last 2 years?

* 13. Number of incidents of violent crime suffered in your household in the past 3 years?

* 14. Has your family been homeless in the past 2 years?

* 15. Do you or does anyone in your house receive any of the following public assistance? Check all that apply.