EmailMeForm
Skyping with Molly Program Evaluation
Thank you for taking the time to complete this form for the Keep Kids Fire Safe Foundation.
Your information is very helpful to the foundation and will allow us to continue to offer and improve upon this program.
Skype #:
Date of program
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Name
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First
Last
Phone
*
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Email
*
School
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Number of children in attendance
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Number of adults in attendance
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Did the program meet your expectations?
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Very good
Good
Neutral
Bad
Very Bad
Comments
How would you rate the quality of the content presented during the program?
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Very good
Good
Neutral
Bad
Very Bad
Comments
How would you rate the quality of the educational materials and activities?
*
Very good
Good
Neutral
Bad
Very Bad
Comments
How would you rate your overall satisfaction of the program?
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Very good
Good
Neutral
Bad
Very Bad
Comments
Would you recommend our program to other teachers?
*
Definitely
Probably
Not Sure
Probably Not
Definitely Not
Comments
Do you have any suggestions on how we can improve our Skyping with Molly program?
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Yes
No
If yes, please feel free to share your comments
What qualitative evidence, if any, is there that students understood the concepts presented?
May we use your comments, including your name in our literature and on our website?
*
Yes
No
Comments
Please feel free to share pictures from your students.
Please feel free to share pictures from your students.
Please feel free to share pictures from your students.
Please feel free to share pictures from your students.
Please feel free to share pictures from your students.
Please feel free to share pictures from your students.
Please feel free to share pictures from your students.
Additional comments? Please feel free to add them here.
Thank you for taking the time to fill out our evaluation form! Please feel free to send additional materials to: The Fire Safety Dogs, c/o Keep Kids Fire Safe Foundation, 106 East Poplar Street, Suite 200, Clarksville, Arkansas 72830