After School Needs Assessment

A survey that helps schools understand what kind of after-school care families need and the obstacles keeping them from accessing it.

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Program or School Name

Please indicate the type of after-school care you currently use

Before-school program After-school program On-site daycare Family or relative care Private nanny None currently

Which of these do you feel keeps you from using the service?

High cost Lack of transportation Schedule conflicts Lack of available spots Quality concerns Not aware of the options

Please select your household's gross income range

Under $25,000 $25,000 - $50,000 $50,000 - $75,000 $75,000 - $100,000 Over $100,000

Number of people in your household

Approximately what time does an adult get home after school hours?

What amount would you consider reasonable to pay for school-age child care PER MONTH/PER CHILD?

Which child-care-related problems have you faced in the past year?

Finding availability Affordability Transportation Quality of care Scheduling conflicts None

Where do your children attend school?

Street Address

City

State / Province

ZIP / Postal Code

Additional notes

Name

First Name

Last Name

Phone number

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