Mourning Parents ACT, Inc.
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Feedback Form
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.
First Name
Last Name (optional)
School or other affiliation
E-mail Address (optional)
Address (optional)
Phone (optional)
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Fax (optional)
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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?
Additional Comments
Select this link for a hard copy feedback form
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