Before/After School Services Question Title * 1. Would you use Before and/or After School Services at your school if they were available? YES NO MAYBE Question Title * 2. What grade(s) do your child(ren) currently attend as of August 2014? K 1 2 3 4 5 6 Question Title * 3. Are you currently using before/after-school childcare services? YES NO Question Title * 4. If you answered Yes to Question 3, how much do you pay for before, after or all day services? If you answered no, how much would you be willing to pay? Currently Pay Willing to Pay Question Title * 5. Please check off the location/type of care you are currently utilizing. Day Care Center At Home Care Other Question Title * 6. If you answered at home care, which of the following is it by? Parent Other adult family member Older sibling Babysitter Other Question Title * 7. To help assess funding needs, please indicate your annual household gross income range. Below $20,000 $20,000 - $29,000 $30,000 - $39,000 $40,000 - $49,000 Over $50,000 Question Title * 8. How many people currently live in your household? Question Title * 9. If before- and after-school services were offered in our school, what would prevent you from using these services? (Check all that apply) Cost Availability Location Transportation Hours Happy with current provider Other Question Title * 10. I am interested in Services for my child(ren) in our school. YES NO MAYBE Yes-but I have no reliable transportation to pick up my child after school Question Title * 11. I am interested in Services for my child(ren) in our school. Before-School After-School Both Question Title * 12. If you answered YES or MAYBE to Question 10, please complete the rest of the survey.Before/After School Care: (Monday through Friday) How many days will you need Before Care? What time would you usually drop off your child(ren)? How many days will you need After Care? What time would you usually pick up your child(ren)? Question Title * 13. Early Release School Days:Will your child attend After-School Care on these days? YES NO Question Title * 14. Special Non-School days (at an additional all day cost) Will you need All-Day Care during teacher workdays? Will you need All-Day Care during holidays? Will you need All-Day Care during school vacations? Question Title * 15. Do any of your children have special needs? Please explain: Question Title * 16. Are there any special programs or services you would like to see for your child(ren) during Before and After School Care? Done