Name:

Gender:

Address:

Date of Birth:

Race/ Ethic Background

Occupation:

Special Accommodation:

How did you hear about us?

Have you used our services before? If so, duration:

Rate your most favourite activities in order of preference, #1 being the most favourite.

Do you feel comfortable spending $10/week for an 8 week program.

What do want to accomplish from the program? - like outcomes etc

What improvements would you like to see in our service?

What is your motivation to join our program?

What are barriers that prevent you from attending recreation and leisure programs?

How many times a week would you like to come to our program?

What time do you prefer coming to our program: give them time frames.

How do you feel about the following themed week? Rate the following #1-#8 - #1 being your most favourite