Summer Reading Registration Form

Use this form to register for 2022 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.

Student Name : Please enter student's first and last name. Required

Student Grade as of April 2022: Required

Address : Please enter student/family mailing address. Include address, city, state and zip all on one line. Required

Any allergies(pet, food, medical, etc.) or health concerns that staff or volunteers should be aware of to better serve your student? Required

Parent/Guardian Name(s): Required

Parent/Guardian phone number: Required

Secondary Emergency Contact: Required

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

Independent

Family

I understand the Paullina Public Library reserves the right to dismiss students/patrons from programs based on behavior. Parents/Guardians will be contact in case of bad behavior/dismissal. Required

Understood.

Photo and/or Video Publicity Permission : The library will occasionally take photographs or video of participants in library programs. By participating in a library program, we may include your student on our website or in other publications. Required

Understood