Please complete the following information for each activity that your class or school completes.
Complete a separate entry form for each activity. The more activities your class or school completes, the more entries you will have in the draw.

Information

Information School Name:
School Address:
City/Town:
Postal Code:
Teacher Name:
Teacher Email Address:

Please choose which activity was completed:

Describe what your class or school did – what, how, and when.

What do you think had the biggest impact on students?

Please share any results from your activities.

How do you or your students/youth plan on sharing what they did and learned with others?

How do you or your students/youth plan on sharing what they did and learned with others? Website, Facebook or Twitter

Newsletter or e-zine

Presentation to another group or school assembly

Article in a local newspaper

Public event

Formal report

We will not have the opportunity to share the results of what we did

Please indicate whether you agree or disagree with each of the
following statements:

	Agree	Disagree	Don't Know
The activity met the goals of my program/curriculum.	Please indicate whether you agree or disagree with each of the following statements: The activity met the goals of my program/curriculum. Agree	The activity met the goals of my program/curriculum. Disagree	The activity met the goals of my program/curriculum. Don't Know
The kids enjoyed doing the activity.	The kids enjoyed doing the activity. Agree	The kids enjoyed doing the activity. Disagree	The kids enjoyed doing the activity. Don't Know
The activity gave participants practical skills and tools that they can use to increase their active transportation	The activity gave participants practical skills and tools that they can use to increase their active transportation Agree	The activity gave participants practical skills and tools that they can use to increase their active transportation Disagree	The activity gave participants practical skills and tools that they can use to increase their active transportation Don't Know

The activity reinforced messages about:

	Agree	Disagree	Don't Know
The need to get tested for asthma and allergies	The activity reinforced messages about: The need to get tested for asthma and allergies Agree	The need to get tested for asthma and allergies Disagree	The need to get tested for asthma and allergies Don't Know
The need to control your asthma and allergies	The need to control your asthma and allergies Agree	The need to control your asthma and allergies Disagree	The need to control your asthma and allergies Don't Know
The need for youth to communicate with teachers and coaches about their asthma and allergies	The need for youth to communicate with teachers and coaches about their asthma and allergies Agree	The need for youth to communicate with teachers and coaches about their asthma and allergies Disagree	The need for youth to communicate with teachers and coaches about their asthma and allergies Don't Know
The need to reduce reliance on cars/use more active transportation	The need to reduce reliance on cars/use more active transportation Agree	The need to reduce reliance on cars/use more active transportation Disagree	The need to reduce reliance on cars/use more active transportation Don't Know

I would do this activity again with another group of youth.

I would do this activity again with another group of youth. Yes

No

Comments, questions, or suggestions to improve the program:

Air Aware Post Activity Report Survey