Popup SurveyThanks for coming to the pop-up today! We hope you and your children found the magic of play in an adventure playground. Please answer for EACH CHILD. ***When you have completed the form, scroll all the way down to the end of the form to sign out. Parent/Caregiver Name * First Name Last Name Email * Date of Pop Up Event * MM DD YYYY Consent * By completing the survey for this event, I consent to Rooted in Play sharing my demographic information and feedback with the Children's Board of Hillsborough County for grant reporting purposes. My information will not be shared with anyone else, and by completing the survey in full, I am helping to keep the popups free for the community. Yes No The popup today helped me: Add to my understanding of the importance of play in my child's/children's healthy development. * Strongly Agree Agree Neutral Disagree Strongly Disagree Get new ideas on how to play at home. * Strongly Agree Agree Neutral Disagree Strongly Disagree Feel more confident about what self-directed play is and how to support it. * Strongly Agree Agree Neutral Disagree Strongly Disagree Child 1 Child 1 Name * First Name Last Name Child 1 DOB * MM DD YYYY Child 1 Grade * PreK or younger Kindergarden 1 2 3 4 5 Middle School High School Is this child eligible for free/reduced lunch? * Yes No Child 1 Gender * Please Select Female Male Transgender Non-binary/non-conforming Prefer not to respond Not Available Child 1 Ethnicity * Please Select Hispanic or Latino Not Hispanic or Latino Refused Not Available Child 1 Race * Please Select Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Two or More Races Refused Not Available A new or improved skill my child showed at the popup today was: * Please check all that apply. Creativity (they used the materials in new and/or unexpected ways) Communication (they used eye contact, gestures, and/or words to “talk” about their play to another child or me) Social (they took turns, shared materials, expressed emotions, played next to or with another child, and/or solved a conflict with me or another child) Physical (they grasped an object, crawled, walked, climbed, balanced, threw or caught) No new or improved skill observed today Child 2 Child 2 Name First Name Last Name Child 2 DOB MM DD YYYY Child 2 Grade PreK or younger Kindergarden 1 2 3 4 5 Middle School High School Is this child eligible for free/reduced lunch? Yes No Child 2 Gender Please Select Female Male Refused Not Available Child 2 Ethnicity Please Select Hispanic or Latino Not Hispanic or Latino Refused Not Available Child 2 Race Please Select Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Two or More Races Refused Not Available A new or improved skill my child showed at the popup today was Please check all that apply Creativity (they used the materials in new and/or unexpected ways) Communication (they used eye contact, gestures, and/or words to “talk” about their play to another child or me) Social (they took turns, shared materials, expressed emotions, played next to or with another child, and/or solved a conflict with me or another child) Physical (they grasped an object, crawled, walked, climbed, balanced, threw or caught) No new or improved skill observed today Child 3 Child 3 Name First Name Last Name Child 3 DOB MM DD YYYY Child 3 Grade PreK or younger Kindergarden 1 2 3 4 5 Middle School High School Is this child eligible for free/reduced lunch? Yes No Child 3 Gender Please Select Female Male Refused Not Available Child 3 Ethnicity Please Select Hispanic or Latino Not Hispanic or Latino Refused Not Available Child 3 Race Please Select Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Two or More Races Refused Not Available A new or improved skill my child showed at the popup today was Please check all that apply Creativity (they used the materials in new and/or unexpected ways) Communication (they used eye contact, gestures, and/or words to “talk” about their play to another child or me) Social (they took turns, shared materials, expressed emotions, played next to or with another child, and/or solved a conflict with me or another child) Physical (they grasped an object, crawled, walked, climbed, balanced, threw or caught) No new or improved skill observed today Comments We would love your feedback! Thank you
