PARENT INFORMATION & SURVEY FORM
Form Submission Date
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
CONTACT INFORMATION
Parent/Guardian
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number #1
*
Enter valid mobile number. Will also be used to receive text msgs.
Format: (000) 000-0000.
Phone Number #2
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
*
Mobile
Home
Work
Email Address
*
CHILD INFORMATION
Child's Name #1
*
First Name
Last Name
Grade
*
Please Select
Grade 6
Grade 7
Grade 8
Parent/Guardian
*
Please Select
Mother
Father
Grandparent
Sister
Brother
Aunt
Uncle
Legal Guardian
Child's Name #2
First Name
Last Name
Grade
Please Select
Grade 6
Grade 7
Grade 8
Parent/Guardian
Please Select
Mother
Father
Grandparent
Sister
Brother
Aunt
Legal Guardian
EMERGENCY CONTACT
Emergency Contact:
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
SURVEY Q&A
Have you registered with your STUDENT ACCOUNT?
*
Please Select
YES, I am registered and an active account user.
YES, I am registered, but not an active account user.
NO, I am not registered. Need registration information.
If not, please contact Juanita Jenkins, PC for assistance in acquiring your NYCSA Creation Code and registration instructions.
Is your child(ren) registered with their STUDENT ACCOUNT?
*
Please Select
YES, he/she is registered and is an active account user.
YES, he/she is registered but is not an active account user(s).
NO he/she is not registered. Need registration information.
If not, please contact Juanita Jenkins, PC for assistance in acquiring your NYCSA Creation Code.
What Informational Resource(s) Are You Most Interested In?
*
Select All that Apply
COVID-19 Information
Nutritional Resources
GED
Housing
Financial Literacy
Domestic Violence
Bullying (Physical/Cyber)
Mental Health
Immigration
Individual Education Plan (IEP)
School Related Information
None At This Time
Select ALL that Apply! Enter Additional Resources Not listed, in the Comments Section below.
What is your preferred form of communication?
*
Please Select
The best time for me to participate in a school related meeting, or activities is:
*
8A-9a
9a-10a
10a-11a
11a-12p
12P-1P
1p-2p
2P-3P
Select all that apply.
Select ALL workshops you'd like to attend:
Select All That Apply
Financial Planning
Law of Attraction
High School Preparedness
Mental Health Awareness (Check-in)
Autism Awareness
Cyber Bullying
LGBTQ+ Awareness
Health & Wellness Series
Home-Based Income Opportunities
Life Insurance
Estate Planning 101
Adult Computer Basics
Community Resources
Know Your Rights: Police Engagement
Click all that apply
What other workshop topics do you suggest be provided:
*
Enter up to 3 suggestions separated by commas.
0/50
I would like to volunteer for the following:
*
Workshop Guest Speaker
PTA Membership
Title I Parent Advisory Council
School Leadership Team
CEC
School Volunteer
Provide Products / Information / Services
Assist w/ JHS 292 Student Alumni Assoc.
Assist w/JHS 292 Parent Alumni Assoc.
Unavailable To Volunteer At This Time
Select ALL that Apply!
RATINGS
How do you rate the safety of the school?
1
2
3
4
5
1 Very Bad 2 Bad 3 Good 4 Very Good 5 Excellent
How do you rate the PTA's Parent engagement efforts?
1
2
3
4
5
1 Very Bad 2 Bad 3 Good 4 Very Good 5 Excellent
How do you rate the Parent Coordinator's engagement efforts?
*
1
2
3
4
5
1 Very Bad 2 Bad 3 Good 4 Very Good 5 Excellent
Do you feel welcome in the building?
1
2
3
Never Sometimes Always
How would you rate this form?
*
1
2
3
4
5
1 Bad 2 Okay 3 Good 4 Great 5 Excellent
HOW CAN WE HELP?
Select the reason for your engagement:
Question
Concerns
Comment
Suggestion
Complaint
COMMENTS:
Enter any question or additional information pertaining to the contents and or the purpose of this form., in 50 words or less.
0/50
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