MommyParties™ sponsored by Bausch & Lomb

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* 1. As a host of this party, it is a requirement that you will allow a qualified and screened eye care professional to attend your party. The eye care professional will engage you and your guests in a discussion about the benefits of daily disposable contact lenses and how they help teens with confidence and achievement - in school, sports and overall. They will also talk about determining when it’s the right time to try contacts, explain the process of being fitted, and can answer any questions about lenses from the moms and teens.

Will you allow an eye care professional to attend your party?

Yes

No - If you selected "No", please do not continue with registration.

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* 2. Are you available to host your party in June 2012?

Yes

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* 3. Do you have one daughter between the ages of 12-17 years old?

Yes

No - If you selected "No", please do not continue with registration

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* 4. Please select "Age" of your daughter:

	12	13	14	15	16	17
Daughter	Daughter 12	Daughter 13	Daughter 14	Daughter 15	Daughter 16	Daughter 17

Other (please specify)

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* 5. Is your daughter currently in need of some form of vision correction?

Yes

No - If you selected "No", please do not continue with registration

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* 6. Does your daughter currently wear glasses or contact lenses?

Glasses

Contact Lenses

Neither glasses or contact lenses

Other (please specify)

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* 7. If your daughter currently wears contact lenses, what brand does she use?

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* 8. Is your daughter currently interested in experiencing contact lenses?

Yes

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* 9. Do you have a local make-up artist in mind that you would like to invite to your party? Please note the make-up artist will not be compensated and is not mandatory.

Yes

Maybe

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* 10. As a host mom for MommyParties, I can provide the following: (check all that apply)

Blog posting, I will email link to MomSelect

Vlog posting, I will email link to MomSelect

Email Pictures of my party to MomSelect

Email video to MomSelect

Tweet using a dedicated hashtag

Post on MommyParties Facebook page

I can’t commit to any of this

Other (please specify)

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* 11. Contact information:

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 12. As previously mentioned, it is a requirement to host an eye care professional during your party. We will work directly with you to coordinate. Our goal is to make this process as easy as we can. Please take a moment and review your schedule before providing us with (3) three potential dates in June 2012 to host your party.

Option #1:

Option #2:

Option #3:

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* 13. If selected, a representative will contact you to schedule an eye care professional for your party.
What time zone are you located?

EST

PST

CST

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* 14. What is the best time to call you?

7 AM – 9 AM

9 AM - 11 AM

11 AM – 1 PM

1 PM – 3 PM

3 PM – 5 PM

5 PM – 7 PM

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* 15. Blog URL:

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* 16. Twitter ID:

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* 17. Tell us about your social networks:

Number of visitors to your blog per month:

Number of "Followers" you have on Twitter:

Number of "Friends" you have on Facebook:

Number of "Followers" you have on Google Friends Connect:

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* 18. If there is an opportunity to invite media to your party and/or participate in an interview at a different time, would you be open to this opportunity? This is not mandatory to participate in this program.

Yes

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* 19. Would you allow 1-2 individuals to attend your party from the agency representing Bausch & Lomb? This is not mandatory to participate in the program.

Yes

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* 2. Are you available to host your party in June 2012?

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* 3. Do you have one daughter between the ages of 12-17 years old?

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* 4. Please select "Age" of your daughter:

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* 5. Is your daughter currently in need of some form of vision correction?

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* 6. Does your daughter currently wear glasses or contact lenses?

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* 7. If your daughter currently wears contact lenses, what brand does she use?

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* 8. Is your daughter currently interested in experiencing contact lenses?

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* 9. Do you have a local make-up artist in mind that you would like to invite to your party? Please note the make-up artist will not be compensated and is not mandatory.

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* 10. As a host mom for MommyParties, I can provide the following: (check all that apply)

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* 11. Contact information:

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* 13. If selected, a representative will contact you to schedule an eye care professional for your party. What time zone are you located?

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* 14. What is the best time to call you?

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* 15. Blog URL:

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* 16. Twitter ID:

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* 17. Tell us about your social networks:

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* 18. If there is an opportunity to invite media to your party and/or participate in an interview at a different time, would you be open to this opportunity? This is not mandatory to participate in this program.

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* 19. Would you allow 1-2 individuals to attend your party from the agency representing Bausch & Lomb? This is not mandatory to participate in the program.

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* 20. Feel free to share any information about being a host for MommyParties or ideas you may have for your party (optional). Thanks!

* 13. If selected, a representative will contact you to schedule an eye care professional for your party.
What time zone are you located?