Free After School Needs Assessment Form Template
After School Needs Assessment Form
Please complete this form to evaluate and identify the needs, interests, and preferences of students and families for after-school programs.
Name
Phone number
Please mark the type of After School care you are currently utilizing.
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Day Care Center
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Family Care Center
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Provider in my home
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Spouse/Partner
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Care by family members
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After School Program
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Care by older sibling
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Not utilizing any After School care
Which one prevents you from utilizing the service?
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Availability
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Location
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Hours of Operation
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Happy with current provider
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Transportation
Please indicate your household gross salary
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Less than $20,000
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$20,000 - $29,000
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$30,000 - $ 39,000
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$40,000 - $ 49,000
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$50,000 - $59,000
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More than $60,000
Number of People in your household
List All the People in Your Household
Role
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Child
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Adult
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Elder
Age
Date of Birth
Need Childcare?
Which Days if Childcare needed
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Sunday
When Childcare needed
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Before School
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After School
Approximately what time does an adult get home after school hours?
What would be the amount you consider reasonable to pay for school-age child care per month/per child?
What childcare-related problems have you faced during the past year?
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Cost of Care
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Finding Temporary Care
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Finding Care for a child with special needs
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Location of care
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Transportation to/from care
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Dependability of care
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No issues
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