After School Needs Assessment Form
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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