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* 1. Rate your overall experience with your before/after school program:

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* 3. Grade Level

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* 4. Are you...

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* 5. Are you...

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* 6. If you are working, how often are you working?

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* 7. How are you taking care of your physical self?

Poor Okay Great
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 8. How are you taking care of your emotional self?

Poor Okay Great
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i We adjusted the number you entered based on the slider’s scale.

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* 9. Which program do you participate in the most?

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* 10. If you are attending your school's BEFORE school program, how often do you participate?

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* 11. If you are attending your school's AFTER school program, how often do you participate?

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* 12. What before/after school activity did you attend the most? If you attended more than one, list in the text box below.

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* 13. As a result of participating in the before/after school program, do you feel...

  All of the time Most of the time Some of the time None of the time
more a part of your school?
like you belong in your school?
you are accepted for who you are?
better able to connect with others?
a sense of purpose in your life?
more engaged in the regular school day?
better able to connect with your teachers?

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* 14. As a result of participating in the before/after school program, do you feel that adults/staff/parents...

  All of the time Most of the time Some of the time None of the time
listen to you?
better understand the real you?
made a positive difference in your life?
see you in a different way?
care more about you?

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* 15. I participate in the before/after school program when...

  All the time Sometimes Not at all Not offered
there are projects that are "hands on"
when projects have a final product or performance
when allowed to be artistic or creative
when challenged by program activities
when program activities are fun

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* 16. In the before/after school program, we...

  All the time Sometimes Not at all Not an opportunity
work together with other students
help one another learn or achieve a goal
resolve conflicts
provide input about activities
attend activities that help in everyday life

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* 17. My before/after school program has helped me...

  Helped me a lot Helped me some Was not helpful N/A or already know/do
prepare for graduation
prepare to get into college or technical school
explore different options
prepare for a job or career

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* 18. My before/after school program has helped me to...

  Helped me a lot Helped me some Was not helpful N/A or already know/do
gain leadership skills
learn and apply new practical skills
discover a new passion
learn about new career options

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* 19. Attending the before/after school program has helped increase my interest in... (select your top choice)

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* 20. Attending the before/after school program has helped increase my grades in...(select your top choice)

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* 21. After each statement, rate how your program is doing from "Excellent" to "I don't see this happening at our program."

  Excellent Pretty good Does this but not inspiring Could use more work in this area I don't see this happening in our program
There is something for everyone regardless of income level, race, ability, special needs, religion, or sexual orientation.
Offers programs or snacks that promote healthy lifestyles and a safe, and positive social environment.
Provides opportunities for academic support and success after high school.
Values our input about adding programs that reflect our interests.
Hires great staff who are positive and make me want to come to the program.
Provides hands on skills/activities to develop skills we need for our future.
Offers engaging clubs and activities that expand our options for jobs, careers, and college.

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* 22. The biggest impact of coming to the before/after school program has been...

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* 23. Please share an important experience you have had during the last year in your before/after school program.

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* 24. If you would you like to participate in a student focus group to provide feedback on your before/after school program, please provide your email below.

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