CES Family Resource Center needs assessment
One form per family please.  This will help us plan programs and services for next year.  
What are your children's ages? (check all that apply) *
Required
Who does your child (or children live) with? *
Required
If you need assistance getting childcare, when?
Clear selection
Does your child have a parent currently on active duty in the military or in the Reserves?
Clear selection
Does your child have a parent currently in jail?
Clear selection
Do you have a need for more after school programs?
Clear selection
Do you have a need for more summer programs?
Clear selection
Please check the most common reason(s) your child is absent from or tardy to school. (check all that apply)
Do you feel confident in helping your child with homework?
Clear selection
Are all children in your home covered by health insurance?
Clear selection
Are all children in your home covered by dental insurance?
Clear selection
If you are pregnant or a new parent (child under 2), do you need resources for you or your baby?
Clear selection
What is your education level?
Clear selection
Do any adults in your home need employment assistance?
Clear selection
Here's a list of common HEALTH concerns that may interfere with your child's learning. Please check any that you feel are currently affecting your child's learning.
Here's a list of common SOCIAL/EMOTIONAL concerns that may interfere with a child's learning. Please check any that you feel are currently affecting your child's learning.
If you want Mrs.  Lowery to  contact you about any of this, please  leave your name, student's name and  your phone number or  email.
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