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Turnoff Week Registration Form 2010 |
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(mail to: Center for Screen-Time Awareness, PO Box 312, South Salem, NY 10590)
Spring___ Fall___ Both___
Name_______________________________________________________________ Name of Participating Organization:_________________________________________________________ Address:_____________________________________________________________ ____________________________________________________________________ Telephone:__________________________________Fax:______________________ Email:________________________________________Website:_________________ A few questions: 1. Is this your first Turnoff Week? _____Yes ____No 2. Has your organization done it before? _____Yes ____No 3. Is the week organization-wide, or limited to a certain class, department or other division of your organization? _____limited _____not limited If limited, how? (cirlce one or add your own comments) just my class just our grade just our section, be specific Comments:______________________________________________ 4. If your organization has participated before, what have the benefits been? _____________________ _______________________________________________________ _______________________________________________________ 5. Have there been any problems? _______________________________________________________ _______________________________________________________ _______________________________________________________ 6. What would you like to get from us that would make this more of a success for you? _____________ _______________________________________________________ _______________________________________________________ 7. Is your organization interested in speakers on this topic? _____Yes ____No 8. Do you visit our website? _____Yes ___No 9. If so, do you find it useful? _____Yes ____No 10. What changes, if any would you like to see to make it more useful? _____No Changes Changes include__________________________________________________ 11. Do you limit screen-time in your personal life? _____Yes ___No 12. Would you consider doing it now? _____Yes ____No 13. Did you know that we have information on the effects of screen-time and other technology for the very young, the not so young and the elderly? _____Yes ____No 14. If you knew that we were working on programs to make people more aware of these issues, would you want to be more involved, visit our website for more information, contact us for the specifics? _____Yes____No 15. Would you consider starting a local chapter of our organization in your community or workplace? _____Yes ____No 16. If yes, would you permit us to contact you? _____Yes ____No If yes, what is the best way to contact you? ______________________________________________ _______________________________________________________ 17. What else would you like us to know? _______________________________________________________ _______________________________________________________ This is for ALL of us, our families and our communities. If you have any questions, feel free to reach out, we want to help you affect positive change, empower each individual to take charge of the technology in their lives and lead healthier and more productive lives. THANK YOU!
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