Community Interest & Demographic Survey

We’re bringing exciting, life-changing programs to your neighborhood! Help us understand your family’s needs and interests by completing this short survey. Your input will support funding efforts to expand our programs and services.

Sign in to Google to save your progress. Learn more
Email *
What is your Zip code *
What city do you live in? *
What county do you live in? *
Is your child currently enrolled as a member of the Better Life Better Living for Kidz (BLBL4K) program? *
What is your child’s gender?  *
How many children (ages 4–18) live in your household? *
What are the age ranges of your children? (Check all that apply) *
Required
What is your relationship to the child(ren)? *
Required
What is your total household income? *
Race/Ethnicity (Check all that apply) *
Required
Does anyone in your household have a disability? *
What is the highest level of education completed in your household? *
Which programs are you most interested in for your child(ren)? (Check all that apply) *
Which of the following technology resources are currently available in your household?
(Select all that apply)
Would your household benefit from any of the following? (Check all that apply) *
Required
What days/times work best for your family to attend programs? (Check all that apply) *
Required
What barriers currently prevent your child from participating in after-school or enrichment programs? (Check all that apply)
Full Name *
Phone Number *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of blbl4k.org.

Does this form look suspicious? Report

Google Forms