PD@your.desktop: Homework Time Afterschool Style

First Name: *

Last Name: *

Title: *

Company: *

Email: *

Address: *

Address Line 2:

City: *

State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *

Zip: *

Phone # : *

YYour primary role in afterschool programs: Select Afterschool frontline staff/teacher Afterschool program director or supervisor Resource and referral staff Consultant, trainer, advisor School administrator District administrator State administrator Other NO role in afterschool programs *

How long have you been in the afterschool field?
years *
months *

How many students typically attend your program each day? *

How many paid staff work in your afterschool program? *

What grades does your program serve? [Check all that apply]*
Pre-K Elementary Middle School High School

Program Setting(s)? [Check all that apply]*
rural small town suburban urban

Why did you choose to attend this session today?

Do you own or have access to Center for Afterschool Education materials (guides, CDs, books)? Select Yes No Don't Know *

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