Thank you for completing and returning this survey to the Youth Services Center.  Your answers will help us plan programs and services for the year.

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* 3. Who do you live with?

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* 4. What is the primary language spoken in your home?

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* 5. Do you have internet access at home?

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* 6. How many adults in your home are:

  0 1 2 3+
Working FULL time
Retired
Unemployed/looking for work
Working PART time
Disabled

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* 7. Do you have a parent/guardian who is currently on military deployment?

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* 8. Do you have a parent/guardian currently in jail?

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* 9. What is your current medical insurance status?

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* 10. Do you have feel there is a need for more after-school or summer enrichment?

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* 11. Do you have a paid job?

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* 12. If yes, how many hours do you work PER WEEK (on average)?

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* 13. Do you give money for family expenses (rent, utilities, food)?

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* 14. Are you confident in your job application, resume-writing, and/or interviewing skills?

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* 15. Do you feel confident in your College Application skills?

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* 16. What do you feel are your top three most important needs in order to make decisions about your future and/or college plans?

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* 17. Are you or your family currently facing any of the following basic needs situations? (Check all that apply)

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* 18. Are you or your family currently facing any of the following medical situations? (Check all that apply)

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* 19. Are you or your family facing any of the following social/emotional situations? (Check all that apply)

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* 20. If you could improve any of the following things about your life, which would be the top three most important things that you would like to improve:

Thank you for completing the survey!
Important: If you are in need of help or services right now, please call or stop by the Youth Services Center.

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