Needs Assessment 2009-2010 scantron - Jessamine County Schools

Please fill out this survey and send back with
your child so that we can assist you better.
Please fill in each bubble completely.
Family Information
How many children live in your home
o 1-2
o 3-4
o 5-6 and more
Are you currently expecting a baby
o Yes
o No
Are you interested in information about preschool
for your 3 or 4 year old
o Yes
o No
Do you have health insurance
o Yes
o No
Are you interested in information about applying
for a Medical Card or K-Chip
o Yes
o No
Are there any adults in your household who
have moved in order to seek agricultural/farm
work (tobacco, timber, hay, livestock, dairy,
fruit/vegetable crops, fishing, etc.)
o Yes
o No
Do you have a child with a special health
care need or disability
o Yes
o No
I would like additional information about:
Child Care, Summer Programs/Activities
o Summer Activities Information
o Before/After School Care
o Child Care facilities in Jessamine County
o Becoming an in home child care provider
o Child Care Assistance
Health Services/Mental Health
o Medical/Dental Care
o Immunizations/Physicals
o Vision Exam
o Mental Health Services
Programs for New/Expectant Parent
o Car Seat Safety
o Child Development
o Health Issues for Infants/Mothers
o Available Community Services
Education and Employment
o Getting your GED
o Learn to read/speak English
Family/Parent Programs
o Parenting
o Discipline
o Basic Nutrition & Meal Planning
o Support Groups (please see below)
o Grief
o Divorce
o Substance Abuse
Family Support
o Field Trip Coordination
o School Supplies
o Utilities Assistance or Referrals
o Basic Needs (please circle below)
o Clothing
o Food
o Housing
Please check all schools attended by all
children in your household.
o JELV
o Nicholasville Elementary
o Rosenwald/Dunbar
o Warner Elementary
o Wilmore Elementary
o Brookside Elementary

Please fill in the information below
Name: ______________________________
Phone: ______________________________
Student: ____________________________
Teacher: ____________________________
Please tell us briefly any other needs you
may as well as any other information
(i.e... questions, requests or suggestions)
for the resource center. Remember the
more we know the more we can help.
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Dear Parent/Caregiver:
Our Family Resource Center is designed to
connect parents to community resources and to
help children be successful in school by removing
barriers to their education. Please help us out by
identifying services that your family could benefit
from. We ask that you complete this survey and
return it to your child’s teacher.
The Family Resource Center is located in the
basement of the Village. We have lots of parent
resource materials that are free to our families.
We also coordinate activities such as Family Fun
Nights. We will provide Family Resource Center
updates in the Village Voice and The FRC
Connection newsletters to keep you informed of
community programs and services we offer.
All information is confidential. If you have any
question, you may call the Family Resource
Center at 858-0789. We welcome your visits!
And we are here to help!
Thank you!
Kelly Sampson
Principal
Joe Brannen
FRC Director
Debbie Cumbie,
FRC Assistant Director
Bev Wagner, R.N.
FRC Nurse
Family
Information
Survey
Questions or Comments
call Joe, Debbie, or Bev
858-0789