Student Survey

First and Last Name *

What grade are you in? *

3rd

4th

5th

6th

7th

8th

1. When you are at home and you get cold, do you have enough blankets to keep you warm? *

Yes

No

2. When you are at home and you get hungry, do you have enough food you can eat? *

Yes

No

3. Do you have enough dress-code appropriate clothing for school? *

Yes

No

4. Do you have shoes that fit? *

Yes

No

5. Do you have socks? *

Yes

No

6. Do you have a winter coat? *

Yes

No

7. Do you have soap to use for taking a bath? *

Yes

No

8. Do you have deodorant? *

Yes

No

9. Is there anything you need help with? *

Yes

No

10. If you answered yes to #9 list some things that you need help with.