The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

pkdhKvdojNY37UIz8RINMM4N6svfqojZRwYuFrtQzwF9ZKsNGkmXHP4dU6CuaLFPry3f37d8woTMh4cRmqURtRHZpT4LBbuxft3SQErizNDEQzy4nCCZ7eqQ

AVG Research Project Eligibility Screen Form (For Parents):

Please complete this form to consider your child for the Active Video Game Research Project. If you have more than one child, please use one form for each.

Thank You!

1. Your Name:

2. Your child's name:

3. What is your child's date of birth:

M-D-Y

4. Is your child a boy or a girl?

Boy Girl

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5. Approximately how tall (in inches) is your child?

6. Approximately how much does your child weight (in pounds)?

7. Has your child played any Active Video Games on Xbox One before?

Yes Unsure Never

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8. Does your child read and speak English fluently?

Yes No

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9. Does your child have difficulties reading or answering test questions?

Yes No

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10. Has your child ever been held back 2 or more grades in school?

Yes No

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11. Is your child able to participate in Physical Education (PE) at school?

Yes No

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Will you move away from the Greater Boston area in the next 6 months?

Yes No

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Does your child have a history of or is he/she being treated for any conditions that would affect how much activity he/she can get (see list below):

-Orthopedic Problems
-Developmental delay, learning disabilities, ADHD
-Autism
-Seizures
-Severe Asthma
-Cerebral Palsy
-Cardiac Condition

Yes No

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Medical Conditions (Please Select):

Orthopedic Conditions

Developmental delay, Learning Disability, ADHD

Autism

Seizures

Severe Asthma

Cerebral Palsy

Cardiac Condition

Specify Orthopedic Condition:

Your Email:

Your Phone Number:

Your Address:

How did you hear about this study?

Other: Where did you hear about this study?

Which after school program?

Which housing development?

Which public event?

Where did you see our poster?

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.