Demographics: Number of people in your household: 1 2 3 4 5 6 7+

What is the age range of people in your household? (please enter the number of people in each age category)

0-2   3-5  6-9  10-14  15-19  20-35  35-50  50-75  75+

Program Interest:

CHILDRENS PROGRAMS:

Soccer for ages 3-5 and 6-9: Interested:   Not Interested:
8 week program starting beginning of May thru end of June.
I would be willing to pay the suggested fee of $30.00 for this program yes no
I would consider being a volunteer for this program yes no

Blastball (introductory tee-ball) for ages 3-5. Interested: Not Interested:
8 week program starting beginning of May thru end of June.
I would be willing to pay the suggested fee of $30.00 for this program yes no
I would consider being a volunteer for this program yes no

Tee-Ball for ages 5-7. Interested: Not Interested:
8 week program starting beginning of May thru end of June.
I would be willing to pay the suggested fee of $50.00 for this program yes no
I would consider being a volunteer for this program yes no

Summer Play Group in the park. Interested: Not Interested:
Various ages and activities. Few hours to half day.
I would be willing to pay the suggested fee of $15.00 per week yes no
I would consider being a volunteer for this program yes no

ADULT PROGRAMS

Ultimate Frisbee: - Interested: Not Interested:
Starting Spring 2009 approximately 8 weeks
I would be willing to pay the suggested fee of $45.00 for this program yes no
I would consider being a volunteer for this program yes no

Beach Volleyball: - Interested: Not Interested:
Starting Spring 2009 approximately 8 weeks
I would be willing to pay the suggested fee of $30.00 for this program yes no
I would consider being a volunteer for this program yes no

Instructional Tennis - Interested: Not Interested:
Starting Spring 2009 approximately 8 weeks
I would be willing to pay the suggested fee of $45.00 for this program yes no
I would consider being a volunteer for this program yes no

CHILDCARE

childcare while adult programs are running? Interested: Not Interested:
I would be willing to pay 2.00 per hour per child yes no
I would consider being a volunteer for this program yes no

Moms 'n Tots - Moms and tots getting together with playground and crafts? Interested: Not Interested:
I would be willing to pay 2.00 per child yes no
I would consider being a volunteer for this program yes no

OTHER PROGRAMS YOU WOULD LIKE TO SEE OFFERED IN BRESLAU….

(Please tell us of any other ideas for programs that you think people would be interested in)

OPTIONAL:

If you wish to have us contact you about any of the above, please include your contact information here:

Name:

Email:

Phone:

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