Living Room
*Name
*Address 1
  Address 2
*City
*State
*Zip
*Email Address

Phone Number

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Check if Applicable Activity Number of participants
Television viewing
Socializing
Studying
Reading 
Playing musical instruments
Using a personal computer
Watching movies
Listening to music
 

Entertaining

 
Adult friends
Children’s friends
Other families
Business guests
Church or social groups
Others
 

Other Activities

 
Games Type:
Hobbies Type:
Crafts Type:
Display of collections Type:
Lighting

Table lamps

Sufficient

Needed

Floor lamps

Sufficient

Needed

Overhead light

Sufficient

Needed

Spotlights

Sufficient

Needed

Other

Sufficient

Needed