YDC/PAL Family Resource Needs Assessment Survey

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* 1. If an afterschool program that offered homework support, mentoring, and enrichment activities were available, would you want your child(ren) participate?

Yes

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* 2. What community do you live in?

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* 3. Does your child attend the same school district in which you live? If not, please list which school district they attend.

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* 4. What grade range does your child(ren) fall in? Check all that apply

K-2nd grade

3rd-5th grade

6th-8th grade

9th-12th grade

My child is not of school age yet

I have no children living in the home

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* 5. Please check 1 or more activities that would interest your child

Art activities

Sport related activities

General science activities

Space exploration activities

Lego builds

The chemistry of cooking/ nutrition

Outdoor (physical) activities

Nature related activities

Technology focused activities

STEAM activities

What do you want to be when you grow up? (visiting different professions, school, tech centers, etc.)

Chess

Quilting

Chess

Jewelry Making

Volunteer/ Community service opportunities

Other (please specify)

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* 6. What would you consider the biggest barrier to regular attendance in an afterschool mentoring program, based on your own family needs or concerns?

Transportation

Program hours (typically 3:00pm-5:30pm)

Time constraint

Lack of student interest

Qualifications of staff

Snacks or meals provided

Child involved in other activities

None

Other (please specify)

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* 7. Are there additional programs you feel your family, or your community would benefit from? Please check all that apply.

Summer Day Camp

After school care

Before school care

Early Childhood Education/Learning centers (child care) with day time hours

Early Childhood Education/ Learning centers (child care) with evening hours

Early Childhood Education/ Learning centers (child care) with over night care

Sports activities

None of the above

Other (please specify)

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* 8. Are there additional RESOURCES you feel your family or your community could benefit from? Please check all that apply.

Resource center/ What recources are available in my community?

Help with obtaining food

Access to medical/dental programs

Mental health resources

Emergency utility assistance (gas, electric, rent etc.)

Child Care Tuition Assistance

Job Search

Other (please specify)

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* 9. Are there children's programs currently available in your community? If so, please share? (for example: after school programs or childcare)

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* 10. How do you hear about children's programs being offered in the community? Please check all that apply.

Paper print ads

Church

Local businesses

Word of mouth

Online search

Facebook or other social media formats

Other (please specify)

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* 11. Are you currently using childcare services?

Yes

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* 12. Are you currently eligible for or receive childcare tuition payment assistance?

Yes

Unknown - pending approval

What is childcare tuition assistance?

Other (please specify)

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* 13. Please choose an option that best describes your current annual household income.

0-$4,999

$5,000-9,999

$10,000-24,900

$25,000-49,000

$50,000 - 79,000

$80,000 and over

Other (please specify)

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* 14. Do you have a need for childcare right now that is not being met? (select all that apply)

Yes - I am in need of child care for an infant, toddler, or preschool age child

Yes - I am in need of child care for my school age child(ren)

My needs are currently being met, but I am open to options with an employer incentive

Not currently, but I will in the future

No - I need 2nd shift child care coverage

No - I need 3rd shift child care coverage

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* 15. Please tell us the age of your child(ren). How many children in each age group do you have in your home?

Infants under 1.5 yrs

Toddler 2.5-3 yrs old

Preschool 3-5 years old

School Age child(ren) K-2

School Age child(ren) 3-5

School Age child(ren) 6-8

High School students

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* 16. There are many opportunities to be a part of our mission to grow our youth for the future. If you are interested:

In being added to our waitlist for the fall

If you or your high school student are interested in being a Mentor

Please take a minute to fill out the following information or visit our website at www.ydcpal.org

Name

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

YDC/PAL Family Resource Needs Assessment

Family Resource Needs Assessment

Question Title

* 1. If an afterschool program that offered homework support, mentoring, and enrichment activities were available, would you want your child(ren) participate?

Question Title

* 2. What community do you live in?

Question Title

* 3. Does your child attend the same school district in which you live? If not, please list which school district they attend.

Question Title

* 4. What grade range does your child(ren) fall in? Check all that apply

Question Title

* 5. Please check 1 or more activities that would interest your child

Question Title

* 6. What would you consider the biggest barrier to regular attendance in an afterschool mentoring program, based on your own family needs or concerns?

Question Title

* 7. Are there additional programs you feel your family, or your community would benefit from? Please check all that apply.

Question Title

* 8. Are there additional RESOURCES you feel your family or your community could benefit from? Please check all that apply.

Question Title

* 9. Are there children's programs currently available in your community? If so, please share? (for example: after school programs or childcare)

Question Title

* 10. How do you hear about children's programs being offered in the community? Please check all that apply.

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* 11. Are you currently using childcare services?

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* 12. Are you currently eligible for or receive childcare tuition payment assistance?

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* 13. Please choose an option that best describes your current annual household income.

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* 14. Do you have a need for childcare right now that is not being met? (select all that apply)

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* 15. Please tell us the age of your child(ren). How many children in each age group do you have in your home?

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* 17. Notes: