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* 1. Does your child need help completing homework after school?

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* 2. If yes, who usually helps your child with his/ her homework?

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* 3. Does your child currently participate in any activities after school?

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* 4. If yes, how often does he/ she participate?

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* 5. If your child does not participate in activities after school, please indicate the reason(s) why:

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* 6. Please indicate the time(s) that your child/children would be likely to attend an afterschool program:

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* 7. Has your child ever witnessed, or been subject to, bullying at his/ her school?

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* 8. How important are the following student services/ activities for an afterschool program?

  Very Important Somewhat Important Not Important
Homework Help
Tutoring
Reading Enrichment
Writing Enrichment
Math & Science Enrichment
Art & Music
Nutrition Education
Sports & Fitness Activities
Drug & Violence Prevention
Anger Management/ Positive Thinking
Community Service Projects
College Readiness
Career & Workforce Readiness

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* 9. Please indicate which parent activities/ services you would be interested in and/or willing to attend.

  Definitely Attend Likely Attend Not Likely to Attend
Family Activity Nights
Parenting Classes
College Applications/ Financial Aid Info
Adult ED- Technology
Adult ED- Resumes
Adult Ed- Literacy
Adult Ed- English as a Second Language

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* 10. Please provide any recommendations you have for community partners or services that should be a part of the 21st Century Community Learning Center afterschool program:

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