Mourning Parents ACT, Inc.
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If you attended one of our presentations and have not previously completed a feedback form, we would like to hear from you regarding our teen driver safety awareness program. Please answer the following questions.
Last Name (optional)
School or other affiliation
E-mail Address (optional)
Do you regularly wear your seatbelt?
Do you drive over the speed limit?
Have you ever been afraid while riding in a car?
Have you ever driven after drinking alcohol?
Have you ever riden in a car with an impaired driver?
Have you been to an !MPACT presentation?
If so, do you think the program will change your future behavior?
Select this link for a hard copy feedback form
Copyright © 2004-2013 Mourning Parents Act, Inc.
P.O. Box 599, Coventry, CT 06238 (860) 742-8933 ······· Please Drive Safely, Someone Loves You!