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Kindergarten Readiness Survey
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1
. Please tell us which location you went to for the Kindergarten Readiness Screening:
Please tell us which location you went to for the Kindergarten Readiness Screening:
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2
.
Child's First and Last Name:
Child's First and Last Name:
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3
.
Child's Birth Date:
MM
DD
YYYY
HH
MM
AM/PM
Please enter 11:11 for the time.
Child's Birth Date: Please enter 11:11 for the time. Month
/
Day
/
Year
Hour
:
Minute
-
AM
PM
AM or PM
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4
. Child's Gender:
Child's Gender:
Girl
Boy
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5
. Child's Race
Child's Race
Caucasian
African-American
Hispanic
Asian
Other, please specify
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6
. Your Relationship to the Child:
Your Relationship to the Child:
Parent
Grandparent
Guardian
Other, please specify
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7
. Language Spoken in Your Home:
Language Spoken in Your Home:
English
Spanish
Other, please specify
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8
. What is your Family Size?
What is your Family Size?
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9
. Number of Adults in the Home:
Number of Adults in the Home:
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10
. Family Income:
Family Income:
Under $25,000
$25,000-$40,000
$40,000-$70,000
Over $70,000
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11
. Guardian's Level of Education
Guardian's Level of Education
Some High School
HS Diploma/GED
Vocational Certificate
Some College
College Degree
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12
. How many children's books are available in the child's home:
How many children's books are available in the child's home:
0-7
8-15
16-24
25 or more
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13
. How often is the child read to at home?
How often is the child read to at home?
Daily
2-3 times per week
Weekly
1-2 times per month
Monthly
Less than monthly
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14
. Would you be interested in receiving free resources and announcements about local family events?
Would you be interested in receiving free resources and announcements about local family events?
Yes
No
15
. If yes, please share your email address:
If yes, please share your email address:
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