Member Intake Survey

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Instructions:
1. This is not a test. There are no right or wrong answers.
2. If you don’t find the answer that fits exactly, use the answer that comes closest.
3. If you need help with a question, raise your hand and quietly ask the staff member helping you today
so that you don’t disturb others around you.

Remember, there are no right or wrong answers – only your opinion and your experiences. Thanks again!

First Name *

Last Name *

What is your Club member ID Number? *

What Clubhouse do you go to? *

DeLue Clubhouse

Dore Clubhouse

Millbrae Community Youth Center at Taylor Middle School (MCYC)

Lomita Park Elementary School

Bayshore School

Other:

What grade are you in? *

Please mark the appropriate answer.

Are you a... *

Please mark the appropriate answer.

Boy

Girl

Read the statements below and select the answer that is true for you *

Please mark the appropriate answer.

Yes

I don't Know

English is my second language

I have access to a laptop/computer at home

I have access to a laptop/computer at school

I have access to internet/WiFi at home

I have access to healthy, fresh food at home

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