Parent(s) Name(s) :
Address : Phone :
Name (s) of child(ren) you have in the 21st Century After School Program :
Grade(s) child(ren) are in :
School(s) child(ren) attend:
Will your child(ren) attend the 21st Century After School Program next school year?
If not, can you tell us why?
Because the 21st Century after school program has been funded at no charge to you or your
family, and we are able to have highly trained teachers and other professional staff, do you feel
that we have accomplished our goal in the areas of educational, social, cultural, and physical
enrichment of your child(ren)?
Please explain why you answered yes or no:
Are there any other comments you would like to make?
May we contact you by telephone about your responses on this questionnaire?