* 1. Would you like your child or children to participate in a after school program? (Check one.)

* 2. What types of activities would you like to see the after school program offer? (Rank your top eight choices from 1 to 8,with 1 as your top choice)

* 3. Please indicate the days and times that you would like your child or children to be able to attend activities? (Check all that apply.)

* 4. Would your child/children need a ride home after school?

* 5. Are you interested in volunteering to help with the after school program?

* 6. In what ways would you like to volunteer? (Check all that apply.)

* 7. Personal Information (optional):

* 8. Your child's/children's names and grades

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