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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?
(Required.)
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?
(Required.)
Yes
No
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3.
Do you have one daughter between the ages of 12-17 years old?
(Required.)
Yes
No - If you selected "No", please do not continue with registration
*
4.
Please select "Age" of your daughter:
(Required.)
12
13
14
15
16
17
Daughter
12
13
14
15
16
17
Other (please specify)
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5.
Is your daughter currently in need of some form of vision correction?
(Required.)
Yes
No - If you selected "No", please do not continue with registration
*
6.
Does your daughter currently wear glasses or contact lenses?
(Required.)
Glasses
Contact Lenses
Neither glasses or contact lenses
Other (please specify)
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?
(Required.)
Yes
No
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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.
(Required.)
Yes
No
Maybe
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:
(Required.)
Name:
Address:
Address 2:
City/Town:
State:
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
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.
(Required.)
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?
(Required.)
EST
PST
CST
*
14.
What is the best time to call you?
(Required.)
7 AM – 9 AM
9 AM - 11 AM
11 AM – 1 PM
1 PM – 3 PM
3 PM – 5 PM
5 PM – 7 PM
15.
Blog URL:
16.
Twitter ID:
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:
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
No
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
No
20.
Feel free to share any information about being a host for MommyParties or ideas you may have for your party (optional). Thanks!
