This questionnaire is designed to help the Leisure Services Department determine the interest in classes focusing on music instruction. We are attempting to discover:

1) General interest in music programs 2) Specific types of musical instruments we should focus on 3) Techniques and/or styles of music to be taught 4) Level of material to be taught

If you are having difficulty with what a question means, Please call (706) 555-5555 or email musicprograms@leisuresociety.com.

I am interested in music classes.
Strongly Disgree		Strongly Agree
1	2	3	4	5
	I like playing my instrument.
Strongly Disagree		Strongly Agree
1	2	3	4	5

Please circle the choice that best answers the question:

I am interested in classes that focus on:

Accordion/Concertina Acoustic Guitar Bagpipes Banjo Bass Guitar/Stand-Up Bass/Washtub Bass Drums Dulcimer (hammered) Dulcimer (lap) Mandolin Violin/Fiddle Whistles/Fifes/Flutes ________________ Other Instrument (please fill in response)

I am interested in classes that focus on:

American Old-Time Music Traditional Irish Music Klezmer Music Bluegrass Music 1920/1930’s Jazz Music ____________ Other Type (please fill in response) Nothing $5-10 $11-25 $26-35 $36-50

Please circle the answer
that best completes the statement:
I consider my music skills to be:
Beginner	Medium			Advanced				Professional Level
	I own this many musical instruments:
None	one				two				3 or more
	I can read music or tablature:
	YES					NO
	I would like to have someone’s advice when considering buying a new or used instrument:
	YES					NO
	If I were to buy an instrument today, I would spend:
$10-50	$51-150	$151-300	$301-500				$501-1000			$1001 or above
	For a one to two hour class, I would pay:

In order for the Leisure Services Department to get our new class offerings to you, we need some information. We will NEVER give out your name or phone number to an outside agency or individual. This is only to establish a mailing list so you can receive our course offering sheets.

Name: ___________________________________

Address: __________________________________

Phone Number: _____________________________

Email Address: _____________________________

We like to give out free class certificates for birthday presents. Please enter your birthday to be entered into our database:

(mm/dd/yyyy) ______________

Do you know someone who would like to have input into what types of music classes we should offer? Please have them call (706) 555-5555 to have a survey mailed to them.

Thank you for your participation! Your input will be used when deciding what types of music classes to include in our class catalog.

If you have any additional comments, please write them in the space below.