PARTICIPANT INTAKE SURVEY: Early Talkers (Birth – Age 2)

Library ____________________________________________________
Parent’s Name _____________________________________________
Phone _____________________________________________________
Child’s name ________________________________________________

 
 


Have you or are you now going to any other parenting or literacy programs?   _____yes                        _____no

If yes, what are the programs?

Do you have a library card?   _______yes                    _______no


In the last month, how often did you…
(Please explain and then check one box for your answer.)

1. Share books with your child?

every day

1 – 3 times a week

rarely or never

 

2. Talk to your child about what is going on around you?
Can you give an example?

every day

1 – 3 times a week

rarely or never

3. Visit the library with your child?

every day

1 – 3 times a week

rarely or never


What do you hope to get out of this program? What do you hope to learn?