Participant Registration Form

Parent/Guardian Information

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* 1. Parent/Guardian First and Last Name

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* 2. Parent/Guardian Gender

Male

Female

Other (please specify)

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* 3. Email

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* 4. Phone Number

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* 5. Address

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* 6. Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 7. Marital Status

Single

Married

Not Married but living with partner

Separated

Divorced

Widowed

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* 8. Parent/Guardian Date of Birth (MM/DD/YYYY)

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* 9. Which County Do You Live In?

Georgetown

Williamsburg

Other

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* 10. How many children ages 0-4 years old will you be signing up on this form?

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* 11. Child 1: First and Last Name

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* 12. Child 1: Date of Birth (MM/DD/YYYY)

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* 13. Child 1: Gender

Male

Female

Other (please specify)

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* 14. Child 2: First and Last Name

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* 15. Child 2: Date of Birth (MM/DD/YYYY)

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* 16. Child 2: Gender

Male

Female

Other (please specify)

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* 17. Child 3: First and Last Name

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* 18. Child 3: Date of Birth (MM/DD/YYYY)

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* 19. Child 3: Gender

Male

Female

Other (please specify)

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* 20. Child 4: First and Last Name

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* 21. Child 4: Date of Birth (MM/DD/YYYY)

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* 22. Child 4: Gender

Male

Female

Other (please specify)

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* 23. Does your child/children attend a Child Care/Learning Center?

Yes

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* 24. If so, what Center?

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* 25. Where will your child/children attend Pre-K?

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* 26. How did you hear about this program?

Library

Social Media

Friend

Flyer

Agency Referral

Other

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* 27. Please Indicate if you have received your Mini-Library

Yes

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* 28. Have you ever gotten any of your books from Miss Ruby's Kids Kiosks? (located in various areas of Georgetown County)

Yes