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School-age Parent/Family Participation Survey

1. Section One (of three)

Everyone who completes a survey will be entered into a quarterly drawing for a $25 gift certificate from your choice of the following stores: Wal-Mart, K-Mart, Target, Staples, or Office Depot.

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* 1. What is your Child's Age (in years)?

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* 2. What grade is your child currently in?

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* 3. What school does he/she attend?

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* 4. In what county is the school located?

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* 5. What was your child's age upon referral to Special Education or Early Intervention?

Less than 1 year

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16 or older

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20% of survey complete.