Student Needs Assessment Survey Question Title * 1. Are you a registered Boys & Girls Clubs Member Yes No Question Title * 2. What is your current grade level? 6th 7th 8th 9th 10th 11th 12th Question Title * 3. What school do you attend? Charles Patterson MS Chaparral HS Copperas Cove Junior HS Eastern Hills MS Ellison HS Harker Heights HS Killeen HS Liberty Hill MS Live Oak Ridge MS Manor MS Nolan MS Pathways Palo Alto MS Rancier MS S C Lee Junior HS Shoemaker HS Smith MS Union Grove MS Question Title * 4. Do you live with someone who is military-affiliated (active-duty, veteran, retired)? Yes No Question Title * 5. What do you do most days after school? Complete homework/read/study Play video games Take care of family members Spend time with friends Use social media Watch TV or videos After-School Activities (Art, sports, music, robotics, dance, fitness, community service, etc.) Other (please specify) Question Title * 6. How do you spend your time on the weekends? Complete homework/read Play video games Take care of family members Spend time with friends Use social media Watch TV or videos After-School Activities (Art, sports, music, robotics, dance, fitness, community service, etc.) Other (please specify) Question Title * 7. How often do you need help finishing your homework? Always Sometimes Never Question Title * 8. Who usually helps you complete your homework? Parent Teacher Friend Sibling/Family Member Nobody Boys & Girls Club Staff/Volunteers Other (please specify) Question Title * 9. Do you have a positive role model at home? Yes No Question Title * 10. If you currently participate in after-school activities, how often do you participate? A few times/month 1 time/week 2-3 times/week 4+ times/week I do not participate in after-school activities Question Title * 11. If you do not participate in any after-school activities, please indicate the reason(s) why: No activities available Available activities do not interest me Activities are too expensive I don't have transportation I care for my family member(s) after school Other (please specify) Question Title * 12. At this time, what do you plan to do after you graduate from high school? Go to a four-year college Learn trade Go to a community college Get a job at a local business Join the military Other (please specify) Question Title * 13. Explain why you think this is the best option for you: Question Title * 14. Have you ever been bullied at your school, or witnessed someone else getting bullied? No Yes (please specify) Next
