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Parent Powered Literacy Project Sign-Up Form
Contact Us:
Kouider Mokhtari -
kmokhtari@uttyler.edu
Hina Rehan -
hrehan@uttyler.edu
LeAnn Nash -
leann.nash@gmail.com
Amber Banks -
abanks@uttyler.edu
*
1.
Parent/Guardian Information:
(Required.)
First Name
Last Name
Email Address
Phone Number
Address
*
2.
Child Information:
(Required.)
Child's Full Name
Child's Age
Preschool, if applicable
*
3.
Additional Children (if applicable):
(Required.)
Child's Full Name
Child's Age
School Name
Grade Level
*
4.
Participation Details:
(Required.)
Preferred Contact Method (Email/Phone/Text)
Availability for monthly meetings (One meeting per month)
Friday [5 pm – 7 pm]
Saturday [11:00 am - 1:00 pm]
*
5.
Additional Comments or Questions:
(Required.)
Parent/Guardian Signature
Date