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Thank you for completing and returning this survey to the Youth Services Center.  Your answers will help us plan programs and services for the year.

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* 1. School Name

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* 2. Who does your child(ren) live with?

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* 3. What grade is your child?

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* 4. Is there someone in your household who needs employment assistance?

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* 5. Are any High School students in your family seeking employment?

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* 6. Does your child have a parent/guardian who is currently on Active Duty Military or in the Reserves?

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* 7. Does your child have a parent/guardian currently in jail?

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* 8. Are all children in your household covered by medical insurance?

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* 9. Are all adults in your household covered by medical insurance?

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* 10. Are all children in your household covered by dental insurance?

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* 11. Are all adults in your household covered by dental insurance?

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* 12. Do you feel confident in helping your child with your school work?

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* 13. Do you have a need for more after-school programs?

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* 14. Do you have a need for more summer enrichment programs?

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* 15. The following is a list of common Health concerns that may interfere with a child’s learning. Please select any concern(s) that you feel is currently interfering with your child’s learning. If you would like to share a concern that is not listed, please share it in the space provided below the list (OTHER).

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* 16. The following is a list of common Social/Emotional issues that may interfere with a child’s learning. Please select any concern(s) that you feel is currently interfering with your child’s learning. If you would like to share a concern that is not listed, please share it in the space provided below the list (OTHER).

Important: If you are in need of help or services right now, please call or stop by the Youth Services Center.
Thank you for completing the survey!

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