Demographic Information

Parent Name *

Email Address *

Phone number (optional, but helpful for notifications of new classes)

What city do you reside in? *

Are you an ESA Family? *

Yes No I don't know, tell me more about this...

How many children do you have who might be interested in classes or activities? *

What age range are your children? (Check all that apply) *

5-89-1112-1515-18

Interests of Your Children

What types of activities are your children interested in? (Select all that apply) *

Other:

What type of educational experiences are you MOST interested in for your children? *

What setting would you like to receive these services? (Select all that apply) *

What days/times are best for your family? (Select all that apply) *

How far are you willing to travel for a class or camp? *

5 minutes or less 10 minutes 15-20 minutes Willing to drive further for the right opportunity

What months are you most interested in signing up for activities? (Select all that apply) *

Fall (Aug-Nov)Winter (Dec-Feb)Spring (Mar-May)Summer (Jun-July)

Would you like to be notified when new classes and programs become available? *

Yes No

If you would like to be notified, enter your email and phone number below. If not, put NA *

Do you currently use Arizona ESA funds? (optional)

Yes No I'm interested in learning more

What else do you wish existed for your child's learning and development outside of school? (optional)

Any other comments or suggestions? (optional)