Introduction

PLEASE ONLY FILL THIS IN IF YOU HAVE NOT COMPLETED THE PAPER COPY OF THIS SURVEY.
This survey asks questions about your child's participation in the after school program this year. Your answers are anonymous, so please do not put your name on this survey. Your answers to this survey will help us improve the after school program.  Thank you for your time.

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* 1. My child attends (pick one):

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* 2. Grade:

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* 4. Gender

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* 5. This is our:

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* 6. How much do you agree with the following statements (check one for each)

  Strongly Agree Agree Disagree Strongly Disagree Don't Know/NA
a. It is important to me that staff and program leaders care about my child.
b. It is important to me that I can talk to the staff and program leaders about any concerns I have.
c. It is important to me that my child enjoys spending time with staff and program leaders.
d. It is important to me that staff and program leaders listen to what my child has to say.
e. It is important to me that staff members communicate with me about the program. 
f. It is important to me that staff and program leaders challenge my child to do his or her best.
g. It is important to me that staff and program leaders are good role models for my child.

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* 7. Social Skills: How much do you agree with the following statements (Check one for each)

  Strongly Agree Agree Disagree Strongly Disagre Don't Know/NA
a. I would like the program to help my child make better decisions
b. I would like the program to help my child get along better with others.

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* 8. Academics and Activities: How much do you agree with the following statements (Check one for each)

  Strongly Agree Agree Disagree Strongly Disagree Don't Know/NA
a. I would like the program to help my child improve his or her grades in school.
b. I would like the program to help my child complete homework
c. I would like the program to help my child learn how to be a leader.
d. I would like the program to help my child take initiative or try new things
e. I would like my child to have more enrichment (art, music, dance, etc.)

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* 9. Behavior: How much do you agree with the following statements (Check one for each)

  Strongly Agree Agree Disagree Strongly Disagree Don't Know/NA
a. I would like the program to help my child become more interested in school.
b.  I would like the program to help my child be more motivated to attend school.
c. I would like my child to learn more about bully prevention

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* 10. What could the after school program do to help your child succeed in school?

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* 11. What types of family events would you be likely to attend in the future?

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* 12. Do you have any other comments for us?

Thank you -- your survey is complete!

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