PARTICIPANT INTAKE SURVEY: Pre-Readers

PARTICIPANT INTAKE SURVEY: Pre-Readers (Ages 4 & 5)

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? Please explain.	every day	1 – 3 times a week	rarely or never
2. Introduce your child to letters, letter sounds and letter names? Can you give an example?	every day	1 – 3 times a week	rarely or never
3. Play word games with your child? Can you give an example?	every day	1 – 3 times a week	rarely or never
4. Help your child build vocabulary through reading books. Can you give an example?	every day	1 – 3 times a week	rarely or never
5. 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?