Survey : Questions

1.

These questions are to be answered by your CHILD / YOUTH that is registered in the After School program.

Please have your CHILD answer each question with how strongly they agree / disagree with each statement.

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not sure / Not applicable
I feel welcome and comfortable at the after school program.
Adults who work at my after school program listen to me.
The adults at the after school program are fair to everyone.
I know who to speak to at the after school program if I have a problem
The adults listen to what I want to do and help me make it happen.
I can rest and relax at the program when I need to.
I like the food here and get enough to eat and drink.
The after school program is clean.
I feel safe while at the after school program.
There are enough things to use here so that everyone gets a turn.

2.

These questions are to be answered by your CHILD / YOUTH that is registered in the After School program.

Please have your CHILD answer each question with how strongly they agree / disagree with each statement.

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not sure / Not applicable
I have friends at the after school program.
I get to choose among a variety of different activities in the program.
I like the activities at my after school program.
There are enough activities for me at the after school program.
Overall, I like coming to the after school program.

3.	Please tell us anything you want about the after school program and activities for children / youth in the space below.
	1000 characters left.

4.

How old are you (child) ?

5-8

9-11

12-15

Other

5.

Your gender (child)?

Male

Female

6.

Please enter the information indicated below (child's information).

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Email Address:	emailaddress@xyz.com