Ballard High School Youth Services Center Needs Assessment Survey
Parent/Guardian Survey
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Who does your child(ren) live with?  *
What grade is your child? (Check all that apply)
 *
Required
Is there someone in your household who needs employment assistance?
Clear selection
Are there any High School students in your family seeking employment?
Clear selection
Does your child have a parent/guardian who is currently on Active Duty Military or in the Reserves?
Clear selection
Does your child have a parent/guardian currently in jail?
Clear selection
Are all children in your household covered by medical insurance?
Clear selection
Are all adults in your household covered by medical insurance?
Clear selection
Are all children in your household covered by dental insurance?
Clear selection
Are all adults in your household covered by dental insurance?
Clear selection
Do you have a need for more after-school programs?
Clear selection
Do you have a need for more summer enrichment programs?
Clear selection

The following is a list of common Health concerns that may interfere with a child’s learning. Please select any concern(s) that you feel is currently interfering with your child’s learning. 

The following is a list of common Social/Emotional concerns that may interfere with a child’s learning. Please select any concern(s) that you feel is currently interfering with your child’s learning. 

Thank you for completing this survey. Your answers will help us plan programs and services for the year.

If you are in need of help or services right now, please stop by or call the Youth Services Center at (Center phone number).
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