SLS PTO CHARITABLE SUPPORT FORM

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Thank you for your willingness to join our database to be contacted for future consumer research studies and supporting SLS PTO. We greatly appreciated it. Diane - Dierckman Research, LLC

What is your first name? *

What is your last name? *

What year where you born? *

What is your gender? *

Female

Male

What is your preferred method to notify you of upcoming consumer research studies *

Cell phone/text

Other:

What is the best email to notify you of upcoming consumer research studies? *

What is the best phone number to notify you of upcoming consumer research studies? *

What categories would be of interest to participate in consumer research? *

Food

Fitness

Apparel

Technology

Family Care (Detergents, paper products, etc)

Beauty Care

General Wellness

Required

In looking for a variety of people, which statement best describes you? *

When I hear about something new, I would consider myself to be one of the first to try it.

I will only try something new if it is recommended to me by a friend.

I often wait until something is proven before I try it.

What is the zip code of your main residence? *

I acknowledge that I am volunteering my time when participating in a research study. The St. Louis School PTO will receive a monetary donation to compensate my participation time. *

Yes

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