General information:
Name: (optional): ___________________
Downriver residence and/or worksite: *List city or township only.
____________________________________________________________
(Residence)                         (Worksite)

Number of years residing and/or working in Downriver area:
___________________________________________________________
(Years residing)                       (Years working)

Current career (if applicable): ___________________________

Questions:

1.  What do you view as the three most prevalent
concerns/problems confronting youth in the Downriver areas
that you are associated with?  (Please specify area)

a.
b.
c.

2.  What suggestions might you offer for addressing these
three concerns/problems?

a.  Ways to address first concern/problem:
    *
____________________________________________________________

____________________________________________________________

 
b.   Ways to address second concern/problem:
    *
____________________________________________________________

____________________________________________________________

 
c.    Ways to address third concern/problem:
    *
____________________________________________________________
____________________________________________________________

 
3.  What do you view as the three most effective programs
that are currently available for youth in your area(s)?
Specify area.

a.__________________________________________________________

b.__________________________________________________________

c.__________________________________________________________

4.  Are you familiar with 4-H programs that are available to
youth/via Cooperative Extension Services(CES) in Wayne
County?

____ Yes   _____ No

5.  Would you like to receive some literature regarding 4-H
programming and CES general program goals?

____ Yes    ____ No

6.  For youth: Ages up to 19 years.

Would you be interested in participating in youth
development programs (i.e., Arts/crafts, computer programs,
clowning, animal science, urban gardening, food/nutrition,
health education, interpersonal skills, video recording,
rapp sessions/support groups, indoor/outdoor sports
recreation, career/educational programs, etc.)  as a 4-H Youth?

____ Yes   ____ No

*If interested, please complete the following on this survey:

Name: _____________________________ Age: _______________
Address: __________________________ telephone #:
_____________

For adults: ages 20 years and up.

Would you be interested in serving as a 4-=H Volunteer
Leader where you could help to facilitate youth development
programs (i.e., Arts/crafts, computer programs, clowning,
animal science, urban gardening, food/nutrition, health
education, interpersonal skills, video recording, rapp
sessions/support groups, indoor/outdoor sports recreation,
career/educational programs, etc.)?

____ Yes   ____ No

*If interested, please complete the following on this survey:

Name: _____________________________ Age: _______________
Address: __________________________ telephone #:_____________

8.  For City Officials:

What resources do you view your city as having available to
assist in the implementation of 4-H Youth Programming (i.e.,
economic, educational, structural resources, etc.)?  Please
be sure to identify your city/township.
*_______________________________________________________
*_______________________________________________________
*_______________________________________________________

9.  For Community Center Administrators:

In what capacities might your center's staff be able to co-
program with 4-H staff to meet the needs of our youth in the
community?  Please be sure to indicate the name of your
center.  You can expect to receive an Wayne County
Agency/Community Group 4-H Enrollment form soon.
*_______________________________________________________
*_______________________________________________________
*_______________________________________________________

10.  For school administrators:

In what capacities might 4-H staff be able to co-program
with teachers in particular classrooms and/or with general
school youth programs?  Please be sure to indicate the name
of your school.  You can expect to receive a 4-H School
Enrollment From soon.
*________________________________________________________
*________________________________________________________
*________________________________________________________

11.  For Church Officials/Clergy:

What roles do you view the church as being able to play to
provide a positive impact upon youth in the community?
Please be sure to identify your church.
*______________________________________________________
*______________________________________________________
*______________________________________________________

12.  For everyone:

Do you have general comments or recommendations for youth
oriented programs in the Downriver area?

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Thank you for your feedback and your time dedicated to
submitting your feedback!!!
 

Cooperative Extension Service programs are open to all
without regard to race, color, national origin, sex or
handicap.

David C. Crawford
County Extension Director & Extension Educator, 4-H/Youth Development
Ohio State University Extension, Stark County
2650 Richville Drive SE Suite 100
Massillon, Ohio 44646