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Name:
Gender:
Address:
Date of Birth:
Race/ Ethic Background
Occupation:
Special Accommodation:
How did you hear about us?
Have you used our services before? If so, duration:
Rate your most favourite activities in order of preference, #1 being the most favourite.
#1
#2
#3
#4
#5
Do you feel comfortable spending $10/week for an 8 week program.
Yes
No
What do want to accomplish from the program? - like outcomes etc
What improvements would you like to see in our service?
What is your motivation to join our program?
What are barriers that prevent you from attending recreation and leisure programs?
Transportation
Weather
Time
Financial
Others:
How many times a week would you like to come to our program?
What time do you prefer coming to our program: give them time frames.
9:00 AM -12:00 PM
12:00 PM - 3:00 PM
3:00 PM - 6:00PM
Other:
How do you feel about the following themed week? Rate the following #1-#8 - #1 being your most favourite
History Week
Magic Week
Let's Get Active Week
Movie Week
Indoor Fun Week
Arts and Crafts Week
Time For You To Shine
Family Week
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