UNITY Mom Advisory Council Application ***Applications due by 3/31/2020*** Mom Advisory Application 1. What is your name?* First Last 2. Are you a mother of 2 or more children between the ages of 9-18, at least one of whom has received an adolescent vaccine (Tdap, HPV, Meningococcal ACWY, Meningococcal B*YesNo3. Which category below includes your age?*25-2930-3940-4950-5960 or older4. What is the highest level of school you have completed or the highest degree you have received?*Less than high school degreeHigh school degree or equivalent (e.g., GED)Some college but no degreeAssociate degreeBachelor degreeGraduate degree5. If employed, what is your job title?6. Why did you vaccinate your child with Tdap, HPV, Meningococcal ACWY or Meningococcal B vaccines?*7. Can you describe an educational campaign that you have seen on vaccines? What did you like/not like about it?*8. Where do you go to get health education on the web? Why?*9. What is your email address?* 10. How did you hear about the Unity Consortium Mom Advisory Board?CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
