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?