Survey of MODIFY Parents on Program Preferences For After School Programs
We need your help in creating an after school program that is helpful to your child and convenient for
you. Please tell us what activities you think we should offer and when, and let us know if you would
like to help develop the after school program. This survey will take only a few minutes to fill out.
Please return this form to INSERT by INSERT DATE, 2007. Thank you for your input!
1. Do you think your child/children would participate in an after school program? (check one)
No
 Yes
2. Do you have a need for a summer program for your children? (check one)
No
 Yes
3. What types of activities do you think an after school program should offer? (check up to four)
 Basketball
 Cooking
Reading tutoring
 Community service
 Cheerleading
 Dance
 Computer/Multimedia
 Gymnastics
 Drama
 Radio
 Martial arts
 Music
 Homework help
 Soccer
 Chess
 Photography
 Softball/baseball
Swimming
 Science experiments
 Volleyball
Help with school projects
 Aerobics
 Arts and crafts
 Other:
Football
Math tutoring
 Other:
 Job search/retention
Independent living
skills
skills
4. What do your children do now after school? (check all that apply)
 Homework

Sports Team

 Chores

Other: ________________
Part time job
5. Please indicate the days that you would like your child/children to be able to attend after school
activities if they were offered in the afternoon after the school day ended? (check all that apply):
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
6. Please check the box that best describes your opinion:
My children currently have a safe place to go during after school hours:
 Strongly disagree
 Disagree
 Agree
 Strongly agree
7. Would your child/children need a ride home after an after school activity?

 No, I would be able to pick up my child/children after an activity.
 Yes, I would need the program to provide transportation for my child/children after an activity.
Circle yes or no:
My child can find someone in our house to help with English/Language homework.
No
Yes
My child can find someone in our house to help with math homework.
No
Yes
Someone in our house would be interested in adult literacy and/or computer classes held at my child’s
school.
No
Yes
Thank You