American Indian Family Center; Survey

Name:
Age:
Grade:
School:
Address:
City/State/Zip:
Phone:
Tribe:
I need tutoring in (check one or more):
	Reading Math Science Other
I prefer to be tutored:
	In Class After School In a Special Area During the Day
Transportation after school would be a problem:
	Yes No
I prefer to be tutored:
	By Myself In a Group
I am most comfortable being tutored by a:
	Student Teachers Aid Teacher Parent
After high school I plan to:

I would like counseling about:

I would like counseling from:
	American Indian Center School Counselor Other
After school I participate in:

I need more information about:
	Careers Scholarships Other
My parents are involved in my education:
	Yes No
School attendance affects my ability to learn:
	Yes No
I would like to learn more about:
	Pow-wow Drumming Language Dancing Local American Indian History Beading Basketmaking Food Preparation Other
Comments: