Fall 2017 Survey Opportunities for Students Question Title * 1. What Time of Day would you like to attend?(check all that apply) Before School 7am-8:20am Afterschool 4pm-6pm Saturday 8am-11am Saturday 11am-1pm Other (please specify) Question Title * 2. Days of the week you would be most interested in(check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday Monday-Friday Other (please specify) Question Title * 3. Transportation I would need transportation in order to attend I do not need transportation Other (please specify) Question Title * 4. Clubs and Activities Running Soccer Dance Tutoring in Math, English Baseball Robotics Science Art Chess Club Building Men Swimming Computer Programming Other (please specify) Question Title * 5. Parents and Families: Preferred Method of Contact Text Message Facebook Twitter Phone(Cell) Phone(House) Email Class Dojo Translated Text Messages(in your preferred language) Recorded phone messages(robo call) Flier Mailings Other (please specify) Question Title * 6. Classes and Programs for Families Zumba Swimming Dance Nutrition/cooking Healthy Living Financial Literacy Computer Skills Job Training Homework Help Parenting Art classes Other (please specify) Question Title * 7. Neighborhood Safety(Check all that apply) I would like to participate in a focus group to discuss neighborhood safety I would like more information about walking safely in the neighborhood I would like to participate in a community Safety Event I am interested in opportunities to establish a better relationship with the Syracuse City Police Department Other (please specify) Question Title * 8. Please check off the supports in Dr. Weeks School you have used: School Based Health Center Medical School Based Health Center Dental School Based Health Center Mental Health Syracuse North East Community Center Food Pantry Syracuse North East Community Center Senior Center Syracuse North East Community Center Teen Programming Syracuse North East Community Center Afterschool Programming Adult Education High school Equivalency Adult Education English as a New Language Mentoring: New York State Mentoring Pass Da Rock Mentoring Promise Zone Arise Huntington Family Centers Family Support Services Hopeprint Mcmahon Ryan Child Advocacy Center Other (please specify) Question Title * 9. What is your gender? Female Male I don't wish to answer Question Title * 10. In what language do you speak most fluently? Arabic Armenian Chinese English French French Creole German Greek Gujarati Hindi Italian Japanese Korean Persian Polish Portuguese Russian Spanish Tagalog Urdu Vietnamese Other (please specify) Question Title * 11. Your relationship to Dr. Week's Elementary School Student Parent/Guardian Grandparent Other Family Member SCSD Teacher/SCSD Contracted Service Provider Question Title * 12. May we invite you to future discussions regarding the community school and/ or request your input regarding the services and programs that we would like to bring into the school? Name Phone Number Email Done