PARTICIPANT INTAKE SURVEY: Talkers

PARTICIPANT INTAKE SURVEY: Talkers (Ages 2 & 3 )

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. Have your child name objects in pictures in books? Can you give an example?	every day	1 – 3 times a week	rarely or never
3. Use general questions to get your child to say more than one word at a time? Can you give an example?	every day	1 – 3 times a week	rarely or never
4. 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?