This survey is for parents with a child younger than one year of age living in Charlevoix, Emmet or northern Antrim Counties that are interested in receiving a Bathtime - Bedtime Literacy Tote.  Northern Antrim County includes Central Lake and Ellsworth.  If you have any questions, you may contact:  gsparents@greatstartforkids.com

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* 1. First Name

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* 2. Last Name

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* 3. Phone Number

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* 4. e-mail address

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* 5. I am a parent with a child less than one year of age.

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* 6. My child's birthdate (MM/DD/YYYY)

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* 7. I live in the following County.

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* 8. What city do you live in?

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* 9. I would like to attend the following event, with my child, to receive my literacy tote.  Check all that are possible for you.  Be aware of any time changes or cancellations due to holidays or weather.

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* 10. Check all the boxes below to acknowledge your understanding.

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* 11. Did you fill out this survey at an event where you received a tote?

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