LOL Book Club Enrollment Form
Please use this form to refer any of your clients to the Love of Learning Book Club Program.
Agency Name *
Your answer
Parent Name (first and last) *
Your answer
Address (street, apt, city, state, zip) *
Your answer
Telephone Number
Your answer
Language preference *
Language(s) spoken at home *
Required
Child #1 at the home (Please include birthday for each child. If prenatal, include due date.) *
Your answer
Child #2 at the home
Your answer
Child #3 at the home
Your answer
Child #4 at the home
Your answer
Child #5 at the home
Your answer
Parent authorizes the agency to share contact information with the Love of Learning book club team. *
Participation in this program requires a commitment from a parent to read aloud at least once a day to the children that receive free books. Is parent willing to make this commitment?
Agency Contact Name (first, last) *
Your answer
Agency Contact Email *
Your answer
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