Parent/Child Adaptive Recreation Programs Interest Survey

Parent/Child Adaptive Recreation Programs Interest Survey

Please complete our brief survey and help The Arc of Warren County provide opportunities that meet the needs of Warren County families for adaptive play and social connection. Thank you in advance for your interest and support!
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number. We will not contact you unless specifically requested at the bottom of this survey.
Address

Street Address

Street Address Line 2

CityState

Zip Code
What is your age?

18-2425-3435-4445-5455-6465+Prefer not to say
What is your gender?

FemaleMaleNon-BinaryPrefer not to say
What best describes your role?

Parent/GuardianCaregiverOther - Please Explain
What age best describes your child or children with special needs? Select all that apply.

0-34-67-910-1213-1516-1819-22Prefer not to sayN/A
Please select the school district your child attends or plans to attend. Select "N/A" if none.
Is your child currently receiving services offered by The Arc of Warren County, including Recreation Services (Camp Warren, Special Olympics, Social Activities, etc.)*

YesNoNot sureNot currently, but has in the pastN/A
Are you interested in participating in CURRENT programs for parents/children with special needs provided by The Arc of Warren County Recreation Services?*

YesNoUnsureN/A
Are you interested in participating in NEW programs for parents/children with special needs provided by The Arc of Warren County Recreation Services?*

YesNoUnsure

On a scale of 1 to 5 please rate your level of interest in participating in any of the following adaptive activities for your child.*

	5 (Very Interested)	4 (Somewhat interested)	3 (Neutral)	2 (Somewhat not interested)	1 (Not at all interested)	N/A
Adaptive Music Classes
Adaptive Art Classes
Adaptive Dance Classes
Adaptive Sports

*By "adaptive" we mean that the needs of all children who attend will be accommodated, be they mobility needs, sensory needs, etc.

**All activities offered we would ask that parents or guardians remain present in the building.

On a scale of 1 to 5, please rate your level of interest in the following opportunities for you and your child.*

	5 (Very interested)	4 (Somewhat interested)	3 (Neutral)	2 (Somewhat not interested or not at this time)	1 (Not at all interested)	N/A
Organized playgroup/open play opportunities with other children of similar ages
Opportunities to connect with other parents of children with similar needs

Please list any other activities or services that you would be interested in seeing offered for your child.

Please select all days/times that would work for you to attend activities with your child.

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please tell us about your child's needs to assist us in better creating fun opportunities for them.
What obstacles would prevent you from attending activities with your child/children? Select all that apply. Select "Other" to include options not listed here.

Work scheduleOther siblings to attend toTransportationUnsurePrefer not to sayOther - Please Explain
Would you like to receive communications from the Recreation Department about upcoming programs, activities, events, etc.?*

YesNo
If "Yes", what is your preferred contact method? Select all that apply. NOTE: We will use the information provided at the beginning of this survey, unless 'Other' is selected.

EmailPhone CallVoicemailPostal MailOther - Click here to provide your preferred contact method.
Thank you for your feedback! Your insights help us discover new opportunities to provide programs and services to individuals with disabilities and their families in Warren County.
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