Parent Survey
  Safe Routes To School Program
What is Your Child's Gender?
What is Your Child's Grade-Level?
What is the approximate distance from your home to the school?
1/4 mile or less
1/4 to 1/2 mile
1/2 to 1 mile
1 to 3 miles
3 to 5 miles
Greater than 5 miles
In which community do you live?

What school does your child attend??

On average, how many times per week does
 this student use the following methods to
 travel to and from school?
  To School From School
  Fall Winter Spring Fall Winter Spring
Walk
Bicycle
Schoolbus
Car
Carpool
Other
Indicate in the table (right), whether or not you feel this student can reasonably walk or bicycle to school.
   Student can
   reasonably: 		Fall Winter Spring
Walk Yes
No 		Yes
No 		Yes
No
Bicycle Yes
No 		Yes
No 		Yes
No
If you drive your child, why do you make that choice? (check as many as apply)
Too far to walk

Safety

Convenience

Drop off on way to work

Inadequate sidewalks

High speed vehicles

Backpacks too heavy

Bulky projects/musical instruments

Scary people

Lack of safe place to store bikes

No biking or walking route maps

Paths are incomplete or not wide enough

Poor visibility or darkness

Child is too young

Slippery, icy, muddy, or unsafe walking surfaces

Cold weather

Child doesn't understand safety rules

Tardiness

No safe place to cross the street

Unfriendly dogs

Other
 
Would you allow your child to walk or bike if: (check as many as apply)
Accompanied by other children

Accompanied by other parents

Provide routes maps

Crossing guards more effective

Safety training for students

Improved sidewalks/bike paths

Cars slowed down

Secure bike storage was available

Paths were separated from traffic

You lived closer to school

Other
 
Would you consider letting your child walk with a group from a school drop off point in the village, with or without an adult escort?
Without adult escort? Yes No
With adult escort? Yes No
Do you feel that the school provides a safe place to store bikes?
 Yes No
Do you have concerns about traffic safety along the routes to school?
 Yes No
If yes, please explain (include specific streets or intersections that are unsafe):
 
 
Would you let your child carpool if:
 You were familiar with the driver
 Someone organized it
Would you be interested in volunteering to help set up or maintain a safe walking or biking program?
 Yes No
If so, please give your name & contact information.
 
Further Comments?

 
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