📚 Empathy Library: Pay It Forward Request Form

Thank you for your interest in receiving free, culturally rich children’s books through The Empathy Library’s Pay It Forward program.

 We distribute books to families, educators, and community organizations serving children in need. Please complete the form below to help us determine eligibility and match you with the best books for your community.

👤 Contact Information

• Full Name (Parent, Guardian, or Educator):

• Email Address:

• Phone Number (optional):
  

🧭 Recipient Type (Check one)

☐ Family / Guardian requesting books for a child at home
☐ Educator requesting books for a classroom or school
☐ Community organization or nonprofit working with youth

📍 Mailing Address (Include Zip Code)

Do we need to require a signature for delivery?

☐ Yes, require signature

☐ No, books will get here safely — no signature required

👧🏽👦🏼 Who Will Receive These Books?

• Number of children you are requesting books for:
  
  
• Grade levels or age ranges (e.g. K–2, ages 4–6):
  
  
• Preferred themes or topics (check all that apply):
  ☐ Joyful Black stories
  ☐ Mental health / feelings
  ☐ Disability / neurodiversity
  ☐ LGBTQ+ inclusion
  ☐ Latinx heritage
  ☐ Immigrant / refugee stories
  ☐ Indigenous culture
  ☐ Strong female leads
  ☐ Social justice / activism
  ☐ General early literacy
  ☐ Other: _____________________________
  
  

💬 Tell Us More (Optional but Helpful)

Is there anything you’d like to share about your situation or why these books would make a difference? (You can also include details like the type of classroom, community, or needs.)

Example: “I teach in a Title I school with mostly Spanish-speaking families.”

📦 Delivery & Distribution

Once verified, if selected - you will be sent delivery information and dates.

✅ Consent & Commitment

☐ I understand these books are a gift through the Pay It Forward program and will be used to support children’s joy and learning. I agree to not sell or redistribute them for profit.

☐I give permission for a photo of the books or a quote from my story to be shared to inspire future donors and families. I will send photos to help keep it going!

Thank you for helping us grow young minds with joyful stories!

📩 Submit your completed form to: EmpathyLibraryBooks@gmail.com