subject_line
Name of Parent/Guardian
*
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip code
*
Phone number
*
Primary language(s) spoken at home:
*
Do you want to add an additional Parent/Guardian?
*
Yes
No
Name of Parent/Guardian
*
Phone number
*
Email
*
Child information
How many children (Kindergarten-Fourth Grade) will you be enrolling in Book Buddies?
*
First Child's name
*
Birthdate
*
+
What grade is this child in?
*
Name of child's school
*
School District
*
Second Child's name
*
Birthdate
*
+
What grade is this child in?
*
Name of child's school
*
School District
*
Third Child's name
*
Birthdate
*
+
What grade is this child in?
*
Name of child's school
*
School District
*
Fourth Child's name
*
Birthdate
*
+
What grade is this child in?
*
Name of child's school
*
School District
*
Emergency contacts
Emergency contact name
*
Emergency contact 1 phone number
*
Relationship to child
*
Parent
Neighbor
Friend
Family member (please indicate relationship)
Family member (please indicate relationship)
Acknowledgements
By checking this box I affirm that I understand I must remain on site during Book Buddies sessions and that children may NOT be dropped off.
*
I understand
Book Buddies sessions may be photographed for archival and marketing reasons. Please check the appropriate box below.
*
Yes, my child's image/voice CAN be used for archival and marketing use.
No, my child's image/voice CAN NOT be used.
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