1. Is your child? Male _____ Female _____

2. What is your relationship to the child?

3. List the racial and ethnic categories, which you would consider yourself to be?

4. What language is usually spoken in your home?

5. Is English your native language?

6. What is (are) the primary language(s) that your child uses at home?

7. How often do you help your child with homework?

8. What type of homework do you help your child with?

9. Is your child involved in any type of activities outside of school?

10. Is your child involved in a music program in school?

11. Do you listen to music at home?

12. Is your child involved in a musical activity outside of school?

13. Does your child play an instrument?

14. What instrument does your child play?

15. *Answered only if question 12 was answered.

Do you have an instrument at home?

16. How often does your child practice their instrument?

17. How much time does your child spend practicing their instrument?

18. Is your child involved in an art program in school?

19. Is your child involved in an art activity outside of school?

20. If your child is participating in a musical activity, have you noticed any improvement in their academic skills? If yes check all that apply.

21. If your child is participating in an art activity, have you noticed any improvement in their academic skills? If yes check all that apply.

22. If your child is participating in a musical activity has it increased their desire to learn? Check all that apply.

23. If your child is participating in an art activity has it increased their desire to learn? Check all that apply.

24. Have you noticed any change in your child’s behavior since they have begun participating in an art/music activity? If yes, in what areas have you noticed the change. Check all that apply

25. Do you think music/art are important to your child’s academic achievement? Please explain.