|
NEW
PROGRAM / ACTIVITY QUESTIONNAIRE FOR REACH CYA
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| Name:
|
|
| Email: (required) |
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| School: |
|
| Grade |
 |
| ACTIVITIES |
| What types of new groups or activities would you
like to see in your school or community?
(please
check all that apply) |
|
|
Discussion
Group
(Topics may include friendship, relationships,
peer pressure, etc.) |
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Education
Group
(Topics
may include substance abuse prevention, homework help) |
|
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Recreation
and Social Group
(Basketball program, golf clinic, etc.) |
|
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Self
Improvement
(Stop Smoking, Weight Loss, Exercise Group) |
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Volunteer
Community Service
(Food
drives, beach clean up, etc.) |
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Other
(Be as specific as you can)
|
|
| IMPORTANT
ISSUES |
| You would
most likely seek help for the following issues:
(please
check all that apply)
|
|
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| GROUPS |
|
How
would you like the groups to be formed? (Please check all that apply.) |
|
All
Girls
All
Boys
Mixed
Group
Doesn’t
matter
|
| |
| MEETING
TIMES |
| When
is the best time for you to attend a group? |
|
In
school at lunch time
Afterschool
Evenings
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| SUGGESTIONS |
| Please
list any other suggestions / ideas here:
|
| Thank
you for taking the time to complete this questionnaire.
Your opinion matters!!! |
|
