Township of Verona Department of Recreation Office of Special Services Survey

Question Title

* 1. Participant's Gender

Male

Female

Non-Binary

Question Title

* 2. Participant's Age

4 and Under

5-8

9-12

13-15

16-18

19-25

26-54

55+

Question Title

* 3. If in school which school does the participant attend

Laning Ave Elementary

FN Brown Elementary

Forest Ave Elementary

Brookdale Ave Elementary

HBW Middle School

Verona High School

Other (please specify)

Question Title

* 4. Sports of Interest for the participant - Please Select all that apply

Basketball

Baseball/Tee-Ball

Soccer

Swimming

Tennis/Pickleball

Spring Track

Cross-Country

Kickball

Other (please specify)

Question Title

* 5. Recreation/Leisure activities of interest- Please Select all that apply

Arts and Crafts

Performing Arts (Theater, Dance, Acting)

Social recreation and clubs

Self-Development Programs

Literary and Reading

Outdoor Recreation (Walks, Hiking, Nature)

Health and Wellness

Board Games

STEM/STEAM

Music

Other (please specify)

Question Title

* 6. Preferred days of the week for activities

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Question Title

* 7. Time of day preferred for activities

Weekdays before 6pm

Weekdays after 6pm

Weekends before noon

Weekends after noon

Question Title

* 8. Types of programming preferred

Self-Contained (limited to individuals with disabilites)

Inclusive (blended)

One-on-one

Exclusive

Reverse Inclusion (Partnered with Neurotypical participants)

All of the above

Question Title

* 9. Disabilities of participant - Answer optional or select all that apply

Autism Spectrum Disorder

Deaf-Blindness

Deafness

Developmental Delay

Emotional Disturbance

Hearing Impairment

Intellectual Disability

Orthopedic Impairment

Specific Learning Disability

Speech or Language Impairment

Traumatic Brain Injury

Visual impairment, including blindness

Multiple Disabilities or other health impairment (please specify)

Question Title

* 10. Which of the following creates the greatest barrier to participating in recreation or sports activities

Lack of early experience opportunities

Lack of understanding or awareness of how to enact inclusion

Limited opportunities and programs for participation

Lack of accessible facilities

Limited accessibility to transportation

Limiting psychological and/or sociological factors including attitudes towards disabilites

Childcare for other children in the family

Classes offered at inconvenient times or dates

Township of Verona Department of Recreation Office of Special Services Survey

Question Title

* 1. Participant's Gender

Question Title

* 2. Participant's Age

Question Title

* 3. If in school which school does the participant attend

Question Title

* 4. Sports of Interest for the participant - Please Select all that apply

Question Title

* 5. Recreation/Leisure activities of interest- Please Select all that apply

Question Title

* 6. Preferred days of the week for activities

Question Title

* 7. Time of day preferred for activities

Question Title

* 8. Types of programming preferred

Question Title

* 9. Disabilities of participant - Answer optional or select all that apply

Question Title

* 10. Which of the following creates the greatest barrier to participating in recreation or sports activities

Question Title

* 11. If you or your child has participated in Verona recreation programs in the past, please tell us what your experience was like

Question Title

* 12. If you would like to be contacted for future programs or announcements please leave your name, email address, and best contact phone number