* 1. At which branch would you like your child to attend EMRL's Summer Reading Program? (You may select more than one!)

* 2. Enter your child's name and age (participants must be aged 4 - 15)

* 3. What is your child's reading level and/or grade level?

* 5. Enter your name, or the name of the child's parent/guardian

* 6. Enter the mailing address for the child's parent or guardian

* 7. Parent/Guardian Phone Number

* 8. Parent Guardian Email Address

* 10. Please type your name below to indicate your understanding that the East Mississippi Regional Library cannot and does not assume responsibility or liability for children while they are at the library, and that your child must be picked up no later than 15 minutes after the end of the program.