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Parent/Guardian Information

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* 1. Parent/Guardian First and Last Name

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* 2. Parent/Guardian Gender

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* 3. Email

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* 4. Phone Number

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* 5. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 6. Race/Ethnicity

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* 7. Marital Status

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

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* 9. Which County Do You Live In?

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* 10. Child 1: Age

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* 11. Child 1: First and Last Name

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* 12. Child 1: Gender

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* 13. Child 2: First and Last Name

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* 14. Child 2: Age

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* 15. Child 2: Gender

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* 16. Child 3: First and Last Name

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* 17. Child 3: Age

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* 18. Child 3: Gender

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* 19. Child 4: First and Last Name

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* 20. Child 4: Age

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* 21. Child 4: Gender

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* 22. Which Child Care/Learning Center does your Child Attend?

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* 23. How did you hear about this program?

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* 24. Georgetown Library Card Number (if applicable)

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* 25. Williamsburg Library Card Number (if applicable)

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

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