Screen Time Action Network Member Application Form
First Name
Last Name
Email
Profession Early childhood educator Educator Nurse Mental health specialist Music/mindfulness/movement provider Attorney Government Other
Organization
Country United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
City
State
Address
Zip/Post Code
Number of Children 1 2 3 4 5 6 7 8 9 10 11 12
First Child's year of birth
Second Child's year of birth
Third Child's year of birth
Fourth Child's year of birth
Fifth Child's year of birth
Sixth Child's year of birth
Seventh Child's year of birth
Eighth Child's year of birth
Ninth Child's year of birth
Tenth Child's year of birth
Eleventh Child's year of birth
Twelfth Child's year of birth
Areas of Expertise
Would you like to be listed in our Action Network Members Directory (which allows participating members to connect by location or profession) by name and city/state? Yes No
What specific interests would you like to share in the Directory? (ex: early childhood, phone-free schools, how to find and build community with like-minded people, etc)
What would you like us to know about you? Feel free to share your own screen time work, your reasons for joining, or anything else!
Religious or Spiritual Tradition Atheism Baptist Buddhism Catholic Christianity Episcopalian Hinduism Islam Judaism Lutheran Methodist Mormon Presbyterian Other Prefer not to say
Race African American Asian Caucasian Caribbean Hispanic Middle Eastern Native American North African Pacific Islander South Asian Mixed Race Prefer not to say Other
Comments
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