City of Coconut Creek Special Needs Interest Question Title * 1. Are you a resident of the City of Coconut Creek? Yes No Question Title * 2. Which category/categories below includes your age or participant with Special Needs? 5-10 11-16 17-21 22-30 31-40 41-50 50 & older Question Title * 3. Please tell us if you or anyone in your household has been diagnosed with any of the following special needs. (Please check all that apply) a. Developmental Delay b. Physical/Medical c. Speech/Language d. Emotional/Behavioral e. Learning f. Other Question Title * 4. Would you or anyone in your household be interested in participating in any of the following special needs activities? (Please check all that apply) a. Arts and Crafts b. Therapeutic Movement (Dance Program) c. Fitness (Adaptive Exercise Program) d. Outdoor Education (Nature) e. Social Programs f. Adaptive Sports g. Other Question Title * 5. What day of the week works best to participate in an activity you are interested in? (Please check all that apply) a. Monday b. Tuesday c. Wednesday d. Thursday e. Friday f. Saturday Question Title * 6. What time of the day works best for you to participate in the activity? (Please check all that apply) a. Morning (8:00am-12:00pm) b. Afternoon (12:00pm-6:00pm) c. Evening (6:00pm-9:00pm) Question Title * 7. If you are interested in special needs activities, please provide your name, phone number and/or email. Call Angela Alvarez, Recreation Programmer, at the Community Center 954-545-6670 for further information or email aalvarez@coconutcreek.net . Done