Chick-fil-A 2017-2018 Mom Panel Registration Survey

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* 1. Contact Information

First and Last Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number:

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* 2. Please select your age group from the categories below.

18-29

30-36

37-41

42-50

51-59

60+

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* 3. Please indicate the number of children in your household.

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* 4. Please select the age of your children. Select all that apply.

Under 2

2-3

4-5

6-7

8-9

10-11

12-13

14-15

16+

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* 5. What is your ethnicity?

Caucasian

African American

Hispanic

Asian

Native American

Indian

Pacific Islander

Prefer not to answer

Other (please specify)

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* 6. How would you classify your current career status?

Full-time in-home working mother

Full-time outside the home working mother

Part-time in-home working mother

Part-time outside the home working mother

In-home mother not contributing income to the family

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* 7. What kind of school(s) do your child(ren) attend? Please select all that apply.

Public School

Private School

Homeschool

Other (please specify)

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* 8. Were you a part of the 2016-17 Chick-fil-A Mom Panel?

Yes

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* 9. Please share links for your social media channels/accounts below to those that apply.

Blog URL

Twitter

Facebook

Instagram

Google Plus

YouTube Channel

Tumblr

Periscope

Other

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* 10. Please share metrics for your social media channels/accounts below to those that apply.

Average Monthly Blog Readers

Twitter Followers

Facebook Friends/Fans

Pinterest Followers

Instagram Followers

Google Plus Followers

YouTube Channel Subscribers

Tumblr Followers

Periscope Followers

Other metrics you’d like to share

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* 11. Approximately how many moms do you communicate with OFFLINE on a weekly basis? (through school, PTA/PTO, moms groups, athletic leagues, workplace, etc.)

Under 20 Moms

20-50 Moms

50-100 Moms

Over 100 Moms

Over 1,000 Moms

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* 12. Please tell us about any other ways you connect with Moms. (Example: Playgroup and meet 30-40 moms each week or month; Write for a parenting publication that reaches 30K families each month, etc.)

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* 13. Please indicate which of the following positions/titles you hold and/or participate in. Please select all that apply:

Author

Columnist for offline publication

Columnist/Contributor for online publication

Business Owner

PTA/PTO Leader

Church/Synagogue Group Leader

TV Contributor

School Board Member

Local Government/City Position

Teacher/Childcare Professional

Coach/Instructor

Other (please specify)

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* 14. Are you currently partnering with any other brands or companies?

Yes

If YES, please list which ones below:

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* 15. How often do you frequent Chick-fil-A?

More than 2-3 times per week

2-3 times per week

Once per week

2-3 times per month

Once per month

2-3 times per year

Once per year

Less than once per year

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* 16. On a scale of 1 to 5, with 5 being extremely positive, how would you rate your overall impression of Chick-fil-A?

Never been to Chick-fil-A

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* 17. How often do you take advantage of the following Chick-fil-A services?

	Weekly	Twice a Month	Once a Month	A Few Times a Year	Never
Kid's Meals	Kid's Meals Weekly	Kid's Meals Twice a Month	Kid's Meals Once a Month	Kid's Meals A Few Times a Year	Kid's Meals Never
Playground	Playground Weekly	Playground Twice a Month	Playground Once a Month	Playground A Few Times a Year	Playground Never
Trays/Catering	Trays/Catering Weekly	Trays/Catering Twice a Month	Trays/Catering Once a Month	Trays/Catering A Few Times a Year	Trays/Catering Never
Family Night Events	Family Night Events Weekly	Family Night Events Twice a Month	Family Night Events Once a Month	Family Night Events A Few Times a Year	Family Night Events Never
Community Events	Community Events Weekly	Community Events Twice a Month	Community Events Once a Month	Community Events A Few Times a Year	Community Events Never
Wifi	Wifi Weekly	Wifi Twice a Month	Wifi Once a Month	Wifi A Few Times a Year	Wifi Never

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* 18. How often do you discuss Chick-fil-A with family and friends?

Daily

Weekly

Twice a Month

Once a Month

A Few Times a Year

Never

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* 1. Contact Information

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* 2. Please select your age group from the categories below.

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* 3. Please indicate the number of children in your household.

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* 4. Please select the age of your children. Select all that apply.

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* 5. What is your ethnicity?

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* 6. How would you classify your current career status?

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* 7. What kind of school(s) do your child(ren) attend? Please select all that apply.

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* 8. Were you a part of the 2016-17 Chick-fil-A Mom Panel?

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* 9. Please share links for your social media channels/accounts below to those that apply.

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* 10. Please share metrics for your social media channels/accounts below to those that apply.

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* 11. Approximately how many moms do you communicate with OFFLINE on a weekly basis? (through school, PTA/PTO, moms groups, athletic leagues, workplace, etc.)

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* 12. Please tell us about any other ways you connect with Moms. (Example: Playgroup and meet 30-40 moms each week or month; Write for a parenting publication that reaches 30K families each month, etc.)

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* 13. Please indicate which of the following positions/titles you hold and/or participate in. Please select all that apply:

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* 14. Are you currently partnering with any other brands or companies?

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* 15. How often do you frequent Chick-fil-A?

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* 16. On a scale of 1 to 5, with 5 being extremely positive, how would you rate your overall impression of Chick-fil-A?

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* 17. How often do you take advantage of the following Chick-fil-A services?

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* 18. How often do you discuss Chick-fil-A with family and friends?

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* 19. What is it that you love most about Chick-fil-A?

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* 20. What would you like to see more of at Chick-fil-A?

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* 21. Is there anything else you’d like to tell us about why you’d like to be a part of the Chick-fil-A Mom Panel?