*1.First Name(Required.)

*2.Second Name(Required.)

*3.Are you...(Required.)

Male

Female

*4.Age?(Required.)

I am under 18

18-24

25-34

35-44

45-54

55-64

I am 65 or over

5.What county do you live in?

AntrimArmaghCarlowCavanClareCorkDerryDonegalDownDublinFermanaghGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryTyroneWaterfordWestmeathWexfordWicklow

*6.Do you have any children under 18?(Required.)

Yes

No

7.If you answered Yes to question 6, please let us know how many children you have?

1

2

3

4

More than 4

*8.If you answered Yes to question 7, please let us know the age range of your child(children)(Required.)

Baby (less than 12 months)

Toddler (1-2)

3-5

6-11

12-17

9.Are you a parent to Boys or Girls? (If so, how many of each do you have?)

1

2

3

4

More than 4

Boy

1

2

3

4

More than 4

Girl

1

2

3

4

More than 4

10.Are you?

Planning on getting pregnant

Currently pregnant

Not planning on getting pregnant in the future

*11.Please supply your email address. (Required.)

*12.I agree to the terms and conditions of being on this panel and am happy for Rollercoaster.ie to contact me in relation to future surveys.(Required.)

Yes

No

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