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?