Rethink your Drink
We want to send you something to help you remember to rethink your drink. Your item and a certificate of completion will be mailed to you.
First and Last Name *
Your answer
Email *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Age *
Sex
Ethnicity *
Race *
Required
How Do You Buy Groceries? Check All That Apply. (You must qualify for SNAP and live in Clinton, Essex, Franklin, Hamilton, Herkimer, Jefferson, Lewis, Oneida, Oswego, or St. Lawrence County to receive your item and certificate.) *
Required
Do You Have Children Living With You? *
True or False? Dividing grams of sugar by 4 will give you the teaspoons of sugar in a drink. *
Based on what I learned today, I plan to drink more water or low-fat milk, or to drink less sugar sweetened beverages *
How did you learn about the 'Rethink your Drink' mobile lesson? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.