musiConnects Demographic Survey (Residency Program)

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We appreciate you taking the time to fill out this *anonymous and confidential* survey, and we understand that personal information is sensitive. This survey does NOT collect names or email addresses, so your responses will be completely anonymous.

To ensure accurate counts, please complete a *separate* survey for each child/sibling in musiConnects programming.

musiConnects takes a holistic approach to teaching each child. We want to make sure that we have the most information possible to help us understand our students' backgrounds. We also want to make sure that we are continually meeting our mission by programming in the most effective ways. Finally, in order for us to bring our programming free of charge to you (aside from the $20 registration fee), we have to raise funds each year. We do this primarily by applying for grants that support music and education. When we ask funders for support, they want to know exactly who we are offering our programs to – they want to know that if they support us, we will use the funding as we have promised.

Does this student attend a Boston Public School?

Yes

Clear selection

What is the primary language spoken in your home?

Are you the student's primary caretaker?

Yes

Clear selection

If you answered "yes" to the previous question, please mark your relationship to the student -

parent

grandparent

aunt / uncle

foster parent

Other:

Clear selection

Please describe your employment status -

Employed

Not employed / currently looking for work

Not employed / not looking for work outside the home

Clear selection

What is the range of your household income?

$15,000 - $25,000

$25,000 - $35,000

$35,000 - $45,000

$45,000 - $55,000

$55,000 and above

Clear selection

Does anyone in your household receive one or more of the following benefits? Please mark all that apply.

Supplemental Security Income Program (SSI)

Temporary Assistance to Needy Families

Special Supplemental Nutrition Program for Women, Infants & Children (WIC)

Does your family live in public housing or Section 8 affordable housing?

Yes

Clear selection

Does your student experience any of the following learning differences?

ADHD

Anxiety

ASD / Autism Spectrum Disorder

Dyslexia

Other:

Feel free to add additional information regarding your previous responses, or general feedback regarding this survey. Again, all answers are anonymous.

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