Summer Reading Program Registration Form

Use this form to register for 2021 Summer Library Program

Please fill out this form to register your child for this year's Summer Library Program. PLEASE REGISTER EACH CHILD INDIVIDUALLY. If you have questions or need help, please call the library at 712-949-3941.

Name : Please enter your child's first and last name. Required

Address : Please enter child's mailing address. Include address, city, state and zip all on one line. Required

Phone number : Enter a phone number where the parent or guardian can be reached. This should be the primary phone. Include area code. Ex: XXX-XXX-XXXX Required

Grade In September : Enter your child's age and the grade your child is going into this fall. If your child is not yet in school enter "Pre" Required

Does the child read alone or do you read to him/her? Select Independent if child reads alone. Select Family if the child will have books read to him/her. Required

Independent

Family

Photo and/or Video Publicity Permission : The library will occasionally take photographs or video of children in the program. May we include your child on our website or in other publications? Required

I give permission.

I DO NOT give permission.

Parent/Guardian signature Required