After School Program Parent Survey (Page 3 of 3) in pdf

After School Program Parent Survey Page 3

(3) _________________________________________________________________________

What three (3) changes would you like to see in the Program?

(1) _________________________________________________________________________

(2) _________________________________________________________________________

(3) _________________________________________________________________________

For each item, please check the description that applies to you.

I have lived in this community for:

[ ] less than one year

[ ] 3-5 years

[ ] 11 years or more

[ ] 1-2 years

[ ] 6-10 years

My child has been in the Program for:

[ ] less than one year

[ ] 1 year

[ ] 2 years

[ ] 3 years or more

Do you own your home?

[ ] Yes

[ ] No

My family income range is:

[ ] $ 5,000 - $ 9,999

[ ] $15,000 - $19,999

[ ] $30,000 - $39,999

[ ] $10,000 - $14,999

[ ] $20,000 - $29,999

[ ] $40,000 - more

Ethnicity:

[ ] African-American

[ ] Asian/Pacific Islander

[ ] Caucasian

[ ] Latino/Hispanic

[ ] Other (please state) _________________________________

After School Program Parent Survey Page 3