Youth Child Survey

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Parent First Name

Parent Last Name

Parent Email

Parent Phone

Child first name

Child last name

Child grade

Best way to get in touch about programming (check all that apply):

EmailPhone callsText messagesFacebookWebsiteInstagramContact child

What days typically work best for programming? (check all that apply):

SundayMondayTuesdayWednesdayThursdayFriday

In your opinion, when is the ideal time frame for a weeknight program?(optional)

In what setting would you feel comfortable having your child participate in?(check all that apply):

ZoomIn-person, physically distancedAlternating virtual and in person programming

Would you be willing to help out at a program on Zoom or in person?

Any additional input(optional):

Mon, October 27 2025 5 Cheshvan 5786

CONGREGATION RODEPH SHOLOM

2713 Bayshore Boulevard

Tampa, FL 33629