2018 Read and Succeed Program Enrollment Form

Please be sure to anser each question as completely as possible so we can process your application as quickly and efficiently as possible.

Enter the Child's full name here.
Enter your street address or PO Box number.
Enter apartment or suite if any.
Enter city or town.
Select state.
Enter Zip Code
Enter the child's age.
Indicate if the child is totally blind or partially sighted.
Enter parent's full name here.
Enter a phone number where you can be reached.
Enter a secondary number where you can be reached.
Which format of books does your child read?
What are your child's hobbies and interests?

If you would like for your child’s book to be sent to his/her school to be read with their teacher we can send it directly to them. Please provide their information below and let them know you have signed your child up for this program and to expect two books (one in the spring and one in the fall). Your birthday gift will come to your home!

Enter the teacher's name if you wish to have the book sent to them directly.
Enter the name of the school to have the book sent to if desired.
Enter the street address of the school you wish to have the book sent to if desired.
Enter any suite or unit number associated with the school if any.
Enter city where school is located.
Select School State
Enter school zip code.