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* 1. Name of head of household:

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* 2. Phone number for head of household (used only to notify winners):

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* 3. Number of Turn Your Screen Off Week participants in your household:

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* 4. Age range of Turn Your Screen Off Week participants in your household: (select all that apply)

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* 5. What area of the county does the household reside in?

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* 6. What 2013 Turn Your Screen Off Week event(s) did you attend?

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* 7. How many total hours did your household keep the "screen" off this week? (screens include TVs, computers, gadgets, and smart phones)

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* 8. Share with us 2 other activities you and/or your household engaged in this week instead of watching TV or playing a computer/device.

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* 9. Which of these prizes would you like to be eligible to win? (select all that apply)

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* 10. Please include any additional comments you would like to share about the Turn Your Screen Off Week here:

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* 11. Please select any newsletter you wish to receive via email and US Mail below (if selections are made, please answer question 12 and/or 13):

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* 12. Please include all email addresses that would like to receive chosen newsletters separated by a comma:

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* 13. What is the Head of Household's address that would like to receive the chosen newsletters above?

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